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? 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 $100 (USD)Your credit card will show a charge from WDMENTALHEALTH (Wendi's therapy business). Please enter your payment information below.Realsteps November 2020Coupon Total $0.00 Credit Card Information* Card Details Cardholder Name Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican 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 RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 NameThis field is for validation purposes and should be left unchanged.