Food Body Love Application

This 10 question application form should take approx 8-10 minutes of your time to complete. We ask you to complete the application form so that both you (and us) can be sure that this program is an appropriate fit for you. It also assists us in ensuring we give you exactly what you are needing for success. Any questions please email louise@louisejeffrey.com. Thank you!

Full Name (required)

Your Email (required)

Phone number

Country you live in

1. What's your biggest challenge with eating and body?
OvereatingEmotional EatingBinge EatingWeightBody Image
If other, please specify:

2. What have you tried in the past to overcome this challenge? (can tick more than one)
DietingExerciseNutritionGroup Therapy1-1 TherapySurgerySupplementsDiet aids
If other, please specify:

3. What has held you back in the past from achieving what you want with food and your body? (What’s been standing in your way?)

4. What is your biggest fear if you don’t overcome this challenge?

5. Describe in a few sentences what you would like to achieve in our sessions together

6. Why is it important for you to achieve this?

7. In one word or a few words, how would you describe your relationship with food?

8. In one word or a few words, how would you describe your relationship with your body?

9. Have there been any family or cultural origins that have influenced your relationship with food and/or your body? If yes, please describe briefly.

10. Besides your eating/body challenges, what else causes you stress in life?

11. When you are upset/frustrated/sad/stressed, what do you do to cope with your feelings?

12. Are you a slow, medium or fast eater?
SlowMediumFast

13. How committed are you to overcoming this challenge? 1=not really 10=fully committed

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14. Please include any other information that may be useful or of relevance .

Thank you for your time!