In order to avoid a substantial waste of our time as well as your time and expectations, before you engage us in the time- consuming, lengthy clinical evaluation, and registration process, we ask you to please start by emailing us the information itemized below and any additional information you may feel would be helpful for us to clinically evaluate your case. Please be accurate, sincere and truthful. The information gathered now and at any time in the future is treated and kept under HIPAA compliance, and will never, ever be shared with anyone outside our Agency. Please use only your first name, and the last four digits of your phone number as your last name. Mark any field with UN if you feel uncomfortable disclosing any specific information. We wish to be the least intrusive. After reviewing your information, we will contact you via email and request a time to speak with you on the phone. INSTRUCTIONS 1) Select and copy the list of question on the panel to the right, 2) Click the button below to generate an email to us, 3) Paste the list of questions on the body of the email, 4) Respond to each one of the questions, be as explicit as necessary, 5) When done, send us the email. We will acknowledge your submission promptly and regardless of the outcome, we will contact you via email after reviewing your request for pre-qualification.

1. Name (Ex: 1st Name + last 4 digits of your telephone number): 2. Age: 3. Gender: FEMALE 4. Height: 5. Weight: 6. Civil status (Ex: Married, Single, Divorced…) 7. Number of children: 8. Number of significant intimate relationships (past and present) 9. Highest level of education: 10. Current job: 11. Source and level of Income: 12. Diabetic? (Ex: Y/N Type 1, Type 2) 13. Medically Fragile (Explain): 14. Require ADA compliance services? Disabled? (Ex: Wheelchair, Deaf. Explain thoroughly) 15. Diagnosed with Sleep Apnea? 16. Can you swim, snorkel, scuba dive? 17. List any and all allergies (past and current): 18. List all major medical issues (past and current): 19. List all your current prescriptions: 20. Mental health issues, diagnosed or suspected? (Ex: Depression, bipolar, anxiety, panic, suicidal, schizophrenia, eating disorders, etc.): 21. Tell use about your medical and recreational substance use/abuse, past and current (Ex. Alcohol, tobacco, marijuana, cocaine, heroine, opioids, sedatives, over-the-counter meds, etc. Be explicit.): 22. How much engineered, commercial junk food do you eat on a daily basis? 23. Diet history. Explain the types and frequency of diets throughout your life. Age of first serious diet, results, most difficult issues to control your weight, most adverse persisting feelings due to overweight, self image issues, etc. Be explicit and extensive. 24. History of weight gains and loses vs age and significant events. 25. Do you feel you weight control issues are due to any of the following: Genetics, metabolic anomalies, psychological factors, stress disorders, overeating, lack of exercising, low self-esteem, loneliness, hypothyroidism, insulin resistance, polycystic ovary syndrome, Cushing's syndrome, lipidemia, etc.? Be explicit, tell us what have you thought it may have been the reason(s) for your persisting weight issues: 26. Do you feel you may be a food addict? A victim of engineered junk food aggressive marketing? 27. Please write anything else that may help us develop an Individualized Treatment Plan, once you qualify to attend our Programs.