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The Mindset Questionaire

Fill out this questionnaire for some self-reflection to see if your mindset is what's holding you back. At the end you'll have an opportunity to book a free mindset discovery call with Dana Lee to talk about the MindFit Mentorship and whether a group program or private coaching could be what will resolve emotional, binge and compulsive eating once and for all.

Click the button below to begin.

Start

Question 1 of 19

Today's Date:

Question 2 of 19

First and Last Name:

Question 3 of 19

 Your Best Email:

Question 4 of 19

Where do you live? (City, State, Country)

Question 5 of 19

How did you hear about Dana or come to know her? (YouTube? Facebook? Through mutual friend? Did you work together in the past? etc)

Question 6 of 19

When it comes to eating what is the single biggest challenge, frustration or problem you've been struggling with and how long has it been a struggle? (Please be as specific & detailed as possible)

Question 7 of 19

When it comes to working out what is the single biggest challenge, frustration or problem you've been struggling with and how long has it been a struggle? (Please be as specific & detailed as possible)

Question 8 of 19

Have you read any books or participated in any programs that you would consider Mindset Work?

A

Yes

B

No

Question 9 of 19

If so, please list the books read and/or programs you've participated in.

Question 10 of 19

Are you trying to follow a particular workout plan now?

A

Yes

B

No

Question 11 of 19

If yes, what outcome are you hoping to achieve from it?

Question 12 of 19

Choose the answer that best describes you:
When I work out, I:

A

Love it - give me more!

B

Endure it - I love the results but wish I didn’t have to work so hard to get them

C

Can’t wait ‘til it’s over - I’ll use any excuse to skip my workout on any given day

D

I don't currently work out

E

I am an on-again / off-again type of exerciser

Question 13 of 19

Select all the things you do on a daily basis (4- 5 times per week).

(Select all that apply)
A

Journal

B

Meditate

C

Affirmations

D

Workout

E

Reward myself with something I love (non-food)

F

Get 8 or more hours of sleep each night

G

Spend time doing something just for me

H

None of the above

Question 14 of 19

Check all that you can identify with:

(Select all that apply)
A

I've been in a lengthy battle with the bathroom scale.

B

The number on the bathroom scale can affect my mood or sense of self-worth.

C

I believe I'll finally be happy and love my body once I reach an "ideal" bodyweight or specific body measurements.

D

I can't remember the last time I wasn't trying to lose weight.

E

I think it's important to finish every workout feeling totally exhausted.

F

I've performed workouts as punishment for overindulging or skipping a workout earlier in the week.

G

I've performed a workout to "earn" the right to eat dessert or my favorite meal or second helping.

H

I determine the value of a workout based on how sore I am the next day.

I

I've been "hating my way" to a lighter/leaner/shapelier body (i.e., you think disliking parts of your body you want to "fix" is good motivation to work hard).

J

Activities I once did for enjoyment (biking, going for a walk, hiking, jogging) are now activities I make myself do solely for the calorie burn.

K

I wish I knew what it was like to look forward to and enjoy my workouts.

L

I want my workout regimen to help me feel good about myself.

M

I've never known any reason to strength train or move a my body apart from the calorie burn or fat-loss potential.

N

I crave a change of pace, a proverbial "breath of fresh air" with my food plan and/or my fitness regimen.

Question 15 of 19

If you enrolled in a Mindset Program, what outcome would you need to have to make it work your time, energy, effort and money? In other words, if I could wave a magic wand over you, what would you want to magically change on the other side? How would you want to FEEL?

Question 16 of 19

Applicable to mothers with children under the age of 16:

Often times mothers are in tremendous need of self care, support, community and a space to do their own work to heal and recover from dysfunctional eating. 

Are you willing to invest money, time and attention in yourself at this stage of your life? (especially knowing that when committing to this work, EVERYONE around you benefits)

(Select all that apply)
A

Yes, I understand and I am ready.

B

No, I don't think I can begin putting myself first yet.

C

I am not a mother, but I AM ready to address these issues.

Question 17 of 19

Is there anything else you'd like to share?
Or, do you have questions for Dana Lee to answer for you?

Question 18 of 19

Name 3 days/times (include your TIME ZONE) that work best for your schedule over the next week or so. This will make coordinating a time for the zoom call easier!

Question 19 of 19

My time and your time is to be valued. Communication and commitment is to be valued.

 

Should you need to reschedule once we set the date, we can do that as long as you let me know in advance (via email or FB messenger)

 

IF HOWEVER, the appointment is a "no show" or it is "forgotten" about, unfortunately we will NOT be able to reschedule.

 

Thank you for acknowledging by checking the box below:

(Select all that apply)
A

I Understand

Confirm and Submit