Application for The Reclaim Your Life From Food Programme


Please fill out the questionnaire below, giving as much information as possible. The aim is for me to assess if I can help you.

Please note that I am on holiday from 27th July to 20th August and will reply to your application when I return.

Thank you for completing this application.


Q1: How often do you binge eat/eat compulsively/overeat?

Q2: How long have you had a problem with food?

Q3: What time of day do you eat the most?

Q4: What have you tried up to this point to deal with this problem? How successful were these strategies?

Q5: Tell me what triggered your last overeating episode (An argument? Stress? Boredom? Be as specific as possible)

Q6: What sort of food did you eat on that occasion?

Q7: How did you feel afterwards?

Q8: How important is secrecy for you when you overeat?

Q9: How well are you able to resist your cravings?
I have a range of strategiesIt dependsI can sometimes resist cravingsI can never resist them - they overwhelm me

Q10: What support do you have to help you with your eating and/or weight problems? (people, websites, books etc)

Q11: What do you normally eat for breakfast?

Q12: If you answered 'other', please describe what you normally eat for breakfast

Q13: If you could magically make your eating problems disappear, how would your life improve? How would you be different?

Q14: Is there any additional information you want to include?


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Thank you very much for completing this assessment. I will be in touch within 48 hours (excludes weekends).