Tailored
Just for you!

$ 39.95

plus taxes
& shipping

Order the tape or CD


Side A: Meeting your needs
Side B: Adjusting your weight
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in Ontario
8% PST
$3.20

In Canada
7% GST
$2.80
Email
:
double check your info for accuracy
Name:
Address:
City:
Prov / State:
Country:
Postal code:
Phone:
Ship by: tape or CD
 
the name my family or friends call me

Chose one :

Don't tell me what to do!
I like being told what to do

A safe place to me would be

near
meadow
woods
trees
creek
lake
waterfall
no water
 or in a
garden
with
fountain
flowers
birds
butterflies
grass
 or on a
hill
mountain
or in a
library
trophy room
studio
describe below

Describe dieting attempts up to now

I need motivation for
more exercise
drink more water
choosing better foods
filling my emotional needs

My health concerns are
general health
tension headaches
bladder control
blood pressure
insomnia
 migraines
nail biting
pain control
concentration
poor memory
other : describe

I am always feel
angry
sad
lonely
bored
 frustrated
insecure
guilty
afraid
 anxious
depressed
not good enough
other
describe other

I am
single
married
common-law
separated
divorced
 widow(er)
my gender
male female
my partner is (was)
male female

In my relationship I need more ... (pick 3)

Admiration
Affection
Appreciation
Companionship
Conversation 		Honesty and Openness
Physical Attractiveness
Domestic Support
Family Commitment
Sexual Fulfillment

Children?

number : ages :

Anything else you would like to add?

Thank you for your order!
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