Name *

First Name

Last Name

Phone *

(###)

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Preferred time of appointments (please check at least two options; SMA groups will meet monthly with individual medical visits in-between): *

8:00 – 9:15 AM on Tuesday

8:00 – 9:15 AM on Thursday

4:45 – 6 PM on Tuesday

4:45 – 6 PM on Wednesday

Areas in which I would like additional support (select as many as apply) *

Nutrition counseling

Stress management and stress eating

Mindset, motivation, setting realistic goals and expectations

Exercise and improving body composition

Weight maintenance