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Worksheet

Maintenance Form

If you've reached your goal in our Weight Loss series, we'd love to help you maintain it! Dr. Lisa Ferlita offers CUSTOMIZED maintenance plans for our clients. Please fill out the following information and she will create one just for you!

1. ➜

Name

2. ➜

Contact Info

Please list your email and phone number

3. ➜

When did you complete your hypnosis series?

It's okay if you don't have exact dates, approximate dates are fine

4. ➜

Height

Feet and Inches

5. ➜

Current Weight

6. ➜

Age

7. ➜

Gender

8. ➜

Activity Level

On average, how active are you?

9. ➜

Goals

10. ➜

Anything else we should know?

Food allergies, health concerns, conditions, mobility issues, etc