SMP- Pre Assessment Form - Antano & Harini

Phone/Mobile

Email

Occupation

Entrepreneur (Less than $10 Million revenue)

Business owner ($10 Million - $50 Million revenue)

Business owner (Above $100 Million revenue)

Freelance professional (Training, Coaching, Baker, etc. )

Senior Management / CXO in Corporations

Middle Management in Corporations

Educationist

Home maker

Student

In the midst of Transition

Other

Marital/Parenting Status:

I’m below 18

Looking for a partner

Not looking for a partner

Separated/Divorced

Married, no children

Married, have a toddler

Married, has teenage child

I’m a Single Parent

I’m a Grandparent

Others

What leads you to binge eating / emotional eating

How long have you been having the challenge of binge eating / emotional eating

What all have you tried till now to overcome binge eating / emotional eating

Why is it important for you to get over binge eating / emotional eating

Lose weight

Get over a medical condition, if yes, pls specify the medical condition

Overcome emotional stress/ anxiety

Others, pls specify

Medical Condition

Specify

On a scale of 0 to 10, “0” being the lowest and “10” being the highest, where would you rate your binge eating habit

0

On a scale of 0 to 10, “0” being the lowest and “10” being the highest, where would you rate your energy level, productivity, emotional states, etc

0

How often do you binge eat in a week

What is the most important thing in your life right now

What do you want in your life 5 years from now