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The more detail you give me the better. I know some of these questions hurt and suck to answer, but I PROMISE you, if you do what I tell you to do, you will be excited to answer them one day. Here we go....
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Indicates required field
Name
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First
Last
Email
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What is your GMAIL email address (needs to be gmail for sheets)
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Occupation
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Date of birth
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Cell Phone Number
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What is your Facebook Name (please friend Dr. Jodi now)
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Who can we thank for referring you to RESET90?
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If you are one of our YL family members, please provide member #
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Are you:
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Single
Married
Dating
Flying solo
Please check all that you want:
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A protocol of supplements, with a review of what I am currently taking
Private, weekly support with Dr. Jodi
Chiropractic care (if not already a patient)
Please check all that you are willing to participate in for acceptance into our culture.
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participation in group calls
sharing wins and challenges in private Facebook setting
committing to giving this a REAL try, for 90 days
Drinking half your weight in ounces of CLEAN water every day
Are you willing to show up EVERY Wednesday evening for our Mastermind Call at 7:30EST? If not, please explain.
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Names and ages of kids:
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Are you currently:
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Nursing
Healing from surgery
Actively losing weight
Struggling with a chronic illness
Addicted to chemical substance
Please explain
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We have options: 2 plans.
Plan 1.
Reset90 Original.
You track EVERYTHING YOU EAT, in MyFitnessPal app, and share a Google Sheet with Dr. Jodi weekly so she can recalibrate / track progress.
Plan 2.
Reset90 Plan B.
No tracking. We co-create your plan, boundaries around food, etc. A bit more free formed, but tailored more for the NON TECHNO ladies.
Which plan best suits you?
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Plan 1
Plan 2
I am not sure, would like to discuss
I used to hate filling this part out, and now I LOVE to. You will get there. We will get you there.
Your current weight
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Your height
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Your ideal weight
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Do you have any current medical condition that you are seeking treatment for?
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Your current exercise routine
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Please tell me about your weight loss journey over the past 20 years.
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Do you have any health issues? Are you on medication? If so please list name, what it is for, and how long you have been on it.
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List the name and brand of each supplement you are currently taking, and what you take it for.
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What is your biggest obstacle right now to achieving your physical goals?
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When was your last physical and what was the outcome?
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Why here, now, with us?
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What are your common thoughts before you fall asleep at night?
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What are your common thoughts when you first wake in the morning?
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What do you TRULY want right now, and what do you feel you need to get it?
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How are you doing physically? What are your biggest obstacles? What are you most proud of?
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How are you doing emotionally? What are your biggest obstacles? What are you most proud of?
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How would reaching your goals serve you? What would be different for you?
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How are you doing spiritually? What are your biggest obstacles? What are you most proud of?
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What foods do you feel best with after eating?
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What have you done in the past with nutrition programing that has REALLY worked for you? What happened that you stopped?
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What foods do feel tired after eating?
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Client Consent to Be Treated
I authorize Dr. Jodi Dinnerman to provide ongoing consulting and support for my health goals. I understand that no guarantees can or will be made as to results of care, treatment, or supplements / diet prescribed and intend this consent to be continuing in nature even after a diagnosis has been made and treatment recommended. This consent will remain in full force until revoked in writing.
Financial Agreement
I acknowledge that I am financially responsible for all services provided and that the program involves a reoccurring payment monthly in the amount advertised. I understand that this amount will be charged to my account monthly until I ask that it is stopped. I acknowledge that all of my questions have been answered about Dr. Dinnerman's services, and that they are not a guarantee of results.
Privacy
I acknowledge that Dr. Dinnerman will not share my information or disclose my involvement with her program outside of the normal and customary procedures of the program (joining facebook community, etc).
Refunds
I acknowledge that my initial investment of $195 for the intake process to Reset90 is non refundable, but can be transferred per the terms described. I acknowldege that my monthly investment, once made, is not refundable but can be used as credit for other services that Dr. Dinnerman offers.
By typing my name below I am consenting to these terms.
Name
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Today's Date
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Home
REMOTE OFFERINGS
Strategy Session
PRIVATE HEALTH CONSULTING
Workplace Wellness
FREE WOMEN COMMUNITY
CHIROPRACTIC / IN PERSON
LightSource Chiropractic
CONTACT / KEEP UP
CONTACT
Feedback
Schedule
Dr. Jodi's WHY
BLOG
Staffless Practice
