Sign Up for RealSteps Step 1 of 3 - About You 0% Your Name* First Last Your Age Range*Under 1818-2425-3435-4445-5455-6465 or AbovePrefer Not to AnswerYour Gender*MaleFemalePrefer Not to AnswerEmail* Do you have any current diagnosed medical (mental health, physical) conditions?*YesNoPlease explainAre you or have you been in the past under the care of a physician for any chronic illness?*YesNoPlease explainWhat are you most unhappy about related to your mental and physical health?*How many times have you tried to go on a diet to lose weight?*01-35+What lifestyle changes have you been successful in?*Why do you want to be part of the RealSteps 30-Day Challenge?*What do you hope to accomplish during the RealSteps 30-Day Challenge?*Anything else you would like us to know about you? Goals: Choose at least one, but no more than 4 goals to work on daily during the RealSteps 30 day challenge.* Goal 1: Daily Breathing Exercises Goal 2: 10 Yoga Moves Goal 3: Daily Cold Showers Goal 4: Exchange your Soda for Water Goal 5: Be in Bed by 10 pm Goal 6: Attempt to get 7-8 hours of sleep each night Goal 7: No screens of any kind 2 hours before bed Goal 8: 15 minutes of connection with a loved one Goal 9: No Social Media Goal 10: Practice a belief or spiritual practice/ 10 minutes of meditation Goal 11: 15 minutes of Mindfulness meditation Goal 12: Daily act of service Goal 13: Enjoy 30-minute meals: sitting down, no screens, nice conversation if possible Goal 14: Make only homemade meals (one lunch or dinner that week, go out to eat if desired) Goal 15: Be outside for 15 minutes daily Goal 16: Eat 3 cups of veggies a day Goal 17: No processed foods. Don’t eat anything that comes out of a bag or that has been processed Goal 18: Drink a lot more water (2-3L daily) Goal 19: Do 10 sit-ups and 10 push-ups every morning Goal 20: Make sure half of your meal is veggies and eat them first Goal 21: Workout every day (guidance on this will be given later) Goal 22: Stand up every 30 minutes and move around a bit Goal 23: Do something that scares you a little bit, every day Goal 24: Learn something new every day Goal 25: Write what you are grateful for in a journal everyday Goal 26: Practice self-compassion Goal 27: Leave your phone behind and wander, sit and think, look up and out at something beautiful Goal 28: Take NO pictures, post nothing, read no one else’s social media posts Goal 29: Express love, appreciation, kindness every day to different people Goal 30: Plan and execute a social gathering at least once a week. It doesn’t have to be big, i.e. 2 people getting coffee or simply chatting on the phone with a long-distance friend or relative counts. Rules* I agree to follow the rules of the RealSteps 30-Day Challenge• No negativity • No trolling or rudeness • Only show support to your fellow RealSteppers • No weighing yourself • No bullying • No talking about diets or your weight • No being rude to yourself about your body • Your job in this group is offer support, encouragement and find connection • Have fun and learn to feel good in your bodyWould you like to participate in the In-depth Treatment option?*Yes, I'd like to be consideredNo, I'm interested in the Group onlyIf so, are you willing to be 100% compliant in following through the individualized plan made for you?* I agree to be 100% compliant.This will include 4 individual therapy sessions and complete nutrition counseling. You must also be available weekdays during daytime hours 9am-4 pm (CST) and have access to a device with a video camera and decent internet for these sessions. The cost to participate in RealSteps is $50 (USD)Your credit card will show a charge from WDMENTALHEALTH (Wendi's therapy business). Please enter your payment information below.Realsteps April 2020Credit Card Information* Card Details Cardholder Name Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country RealSteps Informed Consent and Liability WaiverPlease Read and Sign This Consent Form. Acknowledgement of Health: I declare myself physically and mentally sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation in the RealSteps 30-day Challenge. I acknowledge I have been informed of the need for a physician’s approval for my participation in an exercise/fitness activity or in any dietary changes. I recognize it is my sole responsibility to obtain an examination by a physician prior to involvement in any exercise or nutrition program. I acknowledge I have either had a physical examination and been given my physician’s permission to participate, or if I have chosen not to obtain a physician’s permission prior to beginning this 30-day Challenge. I acknowledge I am doing so at my own risk. I acknowledge and agree no warranties or representations have been made to me regarding the results I will achieve from this program. I understand results are individual and may vary. I acknowledge I have thoroughly read this waiver and release and fully understand it is a waiver and release of liability. By signing this document, I am waiving any right I, or my heirs and/or assigns, may have to bring any and all legal actions or assert any and all claims against RealSteps 30-day Challenge, its respective representatives, executors, and/or assigns. By submitting this form electronically, I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS. Participant Signature*Date* Date Format: MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.