Sign Up for RealSteps – RealSteps for real health

Your Name*
First Last
Your Age Range*
Your Gender*
Email*
Do you have any current diagnosed medical (mental health, physical) conditions?*
- Yes
- No
Please explain
Are you or have you been in the past under the care of a physician for any chronic illness?*
- Yes
- No
Please explain
What 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?*
- 0
- 1-3
- 5+
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?

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 body
Would you like to participate in the In-depth Treatment option?*
- Yes, I'd like to be considered
- No, I'm interested in the Group only
If 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 $100 (USD)
Your credit card will show a charge from WDMENTALHEALTH (Wendi's therapy business).

Please enter your payment information below.
Realsteps February 2021
Coupon
Total
$0.00
Credit Card Information*

Card Details

Cardholder Name
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
RealSteps Informed Consent and Liability Waiver
Please 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
Phone
This field is for validation purposes and should be left unchanged.

Step 1 of 3 - About You

The cost to participate in RealSteps is $100 (USD)

RealSteps Informed Consent and Liability Waiver