S.T.E.P.S. Program® Application
Are you at least 30 pounds overweight and at a turning point in your life?
Are you fed up with the overwhelming heaviness, the debilitating fatigue, and the low self-esteem? Are you ready - finally - to reset your female metabolism so you can have more energy than ever before and stop cravings for good? For over twenty years, Miriam has shown women how to do just that - easily, quickly, and naturally.
Miriam is an internationally recognized weight-loss expert who specializes in rapid results!
She offers private and group coaching programs for women around the world at every stage of life. All programs are structured around her groundbreaking signature system: The S.T.E.P.S. Program® for Permanent Weight-Loss.
Please take your time filling out this confidential application. The more complete your answers, the better Miriam can get to know you. (Information is kept strictly confidential.) To expedite the application process, we ask that you email any recent lab records to email@example.com.
Once we've received your application and lab records, a staff member will contact you to set up a complimentary no-obligation call with Miriam.
During this call, both you and Miriam will decide whether the S.T.E.P.S. Program® is right for you. Miriam will be honest with you about whether she believes the S.T.E.P.S. can help you. If not, she will be glad to refer you to practitioners in other modalities that may be better suited to your needs.
If you both feel that the S.T.E.P.S. can help you, Miriam's assistant will prepare your enrollment packet and your test kits will be mailed to you.
Please note: Submitting this application does not guarantee acceptance into the program.
Serious and appropriate inquiries only.
Today's Date Email Daytime Phone
Full Name Date of Birth
Street Address (no P.O. Box, please)
City/Town State Zip Country
Occupation Age Gender Number of Children
Marital Status: Single Partner Married Separated Divorced Widow
Annual Household Income: $0 to $49,999 $50,000 to $99,999 $100,000 to $149,999 $150,000+
Are you pregnant?Breastfeeding?
Your Weight Today:Your Height:
Have you given birth in the last three months?
Do you get frequent colds or flus?
List any current health problems for which you are being treated:
Current medications (prescription or over-the-counter):
Major hospitalizations or surgeries (including dental): Please list all procedures, complications (if any) and dates:
Check the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest):
1 2 3 4 5 6 7 8 9 10
Identify the major causes of stress (e.g., work, large family, newborn baby, changes in job, residence or finances, legal problems):
Is your lifestyle associated with potentially harmful chemicals (e.g., cleaning products, pesticides, radioactivity, solvents)?
I have: Corrective Lenses Dentures Hearing aid(s) Medical devices/prosthetic/implants
Do you experience any of these general symptoms EVERY DAY?
Neurological Disorders (Parkinson's, paralysis)
Mixed food diet (animals & vegetable sources)
The Zone Diet
The Paleo Diet
The Raw Food Diet
The Macrobiotic Diet
Specific Food Restrictions:
dairy wheat eggs
soy corn all gluten
Specific food restrictions - Other:
When it comes to cravings, what is your #1 biggest challenge? Please describe in detail.
On a scale of 1-10 (10 being the highest), how important is it to you to get this challenge resolved?
Why is losing weight important to you right now?
What is going to happen if you don't lose weight soon?
Specifically how much weight would you like to lose, and by when?
Have you tried other weight-loss programs in the past? Please describe your experiences in detail.
How do you generally receive news and information about nutrition? (From magazines, books, blogs, podcasts, friends, etc.)
Who have been your major role models? What teachers, mentors, books, or experiences changed your life?