Client Name *

First Name

Last Name

Client Date of Birth *

MM

DD

YYYY

Parent/Guardian Name (if applicable)

First Name

Last Name

5. Would you like to experience some positive change in how you think, feel, behave and react around food? *

Yes

No

6. How interested or motivated are you to change how you feel around new food? *

It's time! Let's do it.

I want to, but I'm a bit nervous.

Slightly... but as long as I don't have to put in any effort

Not really... I'm only here because Mum/Dad made me attend