Health Through Diet Coaching Questionnaire

If you are interested in Diet Coaching or Diet Concierge, please fill out the questionnaire below. You will be contacted to set up a no-cost introductory session.

All information is strictly confidential, so feel free to be completely honest on the questionnaire. The more descriptive you are of your situation, the more help that can be offered.


Name *

City & State * (required)

Phone # (optional)

Your Email * (required)

Confirm Your Email * (required)

Relationship to person with diet restrictions i.e. self, partner, parent, friend, etc.: *(required)

Duration on diet (if any): * (required)

Is the person with diet restrictions under the care of a physician or naturopath? * (required)

Are there any additional food allergies or sensitivities? * (required)

Briefly describe your situation and the need for coaching: * (required)

By checking the box in the field below, you understand that I am not a doctor, medical professional or mental health professional, counselor or therapist. I do not offer medical advice. I am offering my services as a coach. Please read Wikipedia’s definition of coaching at: wikipedia.org/wiki/Coaching. When appropriate, I may encourage you to seek assistance from a licensed professional. For instance, if you are taking long term medication for any illnesses, I would encourage you to discuss health issues with your personal doctor. Do you understand? *(required)
Yes, I understand and agree

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