1. First Name*

2. Last Name*

3. City, State (or region), & Country*

4. Email address*

5. Age*

6. Sex*

Male

Female

7. Height*

8. Weight *

9. Do you want to...*

Lose weight only

Get rid of chronic disease only

Both - lose weight and get rid of chronic disease

10. What chronic diseases do you have, if any?*

11. Please list any other health problems or concerns you have.*

12. Why do you want to do this program?*

13. How many medications are you on, and what conditions are they for?*

14. Are you currently taking any GLP-1 weight-loss or diabetes drugs such as Ozempic, Wegovy, Zepbound, Rybelsus, Mounjaro, Saxenda, Victoza, or any others? If so, which one / ones?*

15. What side effects, if any, do you experience from the medications you take? *

16. What food restrictions or allergies do you have such as gluten intolerance, nut allergies, etc.? *

17. What kind of weight-loss programs, diets, or strategies have you tried in the past, if any, such as calorie restriction, low-carb, Keto, Paleo, Adkins, the South Beach Diet, Weight Watchers, etc.?*

18. What kind of exercise programs have you tried in the past, if any, such as running, swimming, walking, lifting weights, spinning classes, aerobics, etc. *

19. Do you sometimes overeat or binge to self medicate?*

Yes

No

20. Do you smoke? *

Yes

No

21. Do you typically consume more than one drink of alcohol per day?*

Yes

No

22. Are you open to revisiting your current beliefs about what foods are / are not healthy and contribute to weight loss or weight gain? *

Yes

No

23. Are you willing to try new foods and to learn how to like healthy foods you might not have enjoyed before? *

Yes

No

24. Are you willing to commit the time to attend the online group educational and cooking sessions, movie nights, preparing food on your own, etc.? *

Yes

No

25. Are you willing to watch up to one full-length documentary or other video about food and health each week? *

Yes

No

26. Do you have the support of the other people in your household to make improvements in your eating habits and lifestyle? *

Yes

No

I am the only person in my household

27. Are you willing to give the program everything you've got, to look for ways to overcome obstacles, and do what you can to make the process of losing weight and / or preventing and reversing chronic diseases as much fun as humanly possible? *

Yes

No

28. If accepted into the program, will you agree to have a doctor monitor your progress so he or she can adjust your medication levels as needed?*

Yes

No

29. What else should we know or would you like to tell us?

30. Waiver Goes Here *

Apply

We require an application because there are a limited amount of people we can work with at a time, and we want to make sure those who do the program are serious about making the shift to a healthier lifestyle.

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You can do it when you make it fun!

We offer three packages...

Bronze - You get the yearlong program including group sessions, cooking classes, and movie nights $2,400 - (Figure out how to put a line through the $2,400) Pay what it's worth to you.

Silver - $3,000 (cross this out and put $2,400 instead) - Includes everything in Bronze plus x number of sessions with an accountability partner and coach who is avilable for up to 12 sessions of 25 minutes long and x number of dollars worth of organic whole grains, legumes, and seeds that we'll use in the cooking program.

Gold - $3,600 - (Cross this out and put $3,000 instead) - Includes everything in Silver plus your own accountability partner and coach who is available for 12 sessions up to 55 minutes long.

While you may upgrade to a more premium package later, you'll save money buying it in advance.

You will not be charged unless your application is approved.

Apply

You can do it when you make it fun!

Make It Fun Health