Name
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First Name
Last Name
Email
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Phone
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(###)
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Age
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Where are you located?
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
In your own words, what brought you here today?
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In your own words, what brought you here today?
Complete this sentence: "I'll know this program worked when..."
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Be specific. What does freedom actually look like for you?
How long have you been struggling with food and your body?
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Which of these statements resonate most with where you are right now?
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(Check all that apply)
What does a typical "struggle day" with food look like for you?
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Walk me through it—from morning to night. What are the thoughts? The behaviors? The feelings?
What would change in your life if food became completely neutral? If you simply allowed yourself to experience a meal?
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If you woke up tomorrow and food fear was just... gone. What would you do differently? What would become possible?
7. What diets, programs, or approaches have you tried? (Check all that apply)
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What worked temporarily? What didn't work at all? What made things worse?
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Have you ever been diagnosed with or treated for any of the following? (Check all that apply)
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If yes, are you currently working with a therapist or mental health professional?
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Do you have any medical conditions or take any medications that affect your eating, metabolism, or relationship with your body?
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Examples: PCOS, thyroid conditions, diabetes, hormonal imbalances, medications that affect appetite or weight, chronic pain, autoimmune conditions, etc.
Are you currently working with any healthcare providers?
Examples: doctor, therapist, dietitian, psychiatrist, naturopath, etc.
What would need to happen to move you closer to a 10?
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This program requires you to challenge beliefs you've held for decades—about food, your body, and your worth. Which of these scares you most?
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What support do you have in your life right now?
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Who knows you're struggling? Who would support this journey? Who might resist or undermine it?
Complete this sentence: "The voice in my head that keeps me stuck sounds like..."
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What does it say? Whose voice is it (yours, your mother's, society's)? When is it loudest?
This program requires a 90-day commitment with weekly 50-minute sessions. Can you realistically commit to:
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- Weekly coaching sessions (same day/time each week)
- Daily/regular use of journal prompts and practices
- Responsive communication between sessions when you're struggling
- Doing the internal work even when it's uncomfortable
What's your time zone?
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What days/times work best for weekly sessions?
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The investment for this program is $3,997. How does this feel for you?
What would make this a "hell yes" decision for you?
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What would need to be true for you to feel absolutely certain this is the right move?
If you could write a letter to yourself one year from now—after completing this program—what would you hope she could tell you?
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What would freedom have given her? How would she describe the woman she's become?
What are you most afraid will happen if you DON'T do this work?
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Not just next month—but 5 years from now. 10 years. The end of your life.
Is there anything else you want me to know about you, your story, or what you need?
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This is your space to share anything that feels important and didn't fit anywhere else.
If we're the right fit, how soon are you hoping to start?
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How did you hear about this program?
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By submitting this application, I understand that:
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By submitting this application, I understand that:
- This is an application, not a guarantee of acceptance into the program
- Mindy Gorman-Plutzer will review my application and may follow up with questions or schedule a brief clarity call
- This program is not a substitute for medical or mental health treatment (though it can complement it)
- I'm seeking food freedom and body trust, not weight loss
- I'm ready to do uncomfortable internal work and challenge decades of conditioning
