Wellspring Academies DVD & Brochure
Please complete the information below to receive a FREE DVD and brochure on Wellspring Academies. - If you would rather receive information about Wellspring Camps (weight loss summer programs for ages 5 – 24),click here.
- If you would rather receive information about Wellspring Women's Program (weight loss programs for women ages 25 – 65+), click here.
If you have questions you'd like answered right away, please call us at 866.277.0145,
or
Chat Now
|
Required fields are indicated by a •
All information remains strictly confidential.
|
|
Your First Name: •
|
|
|
Your Last Name: •
|
|
|
Who is Inquiring: •
|
|
|
Student's First Name: •
|
|
|
Student's Last Name: •
|
|
|
Student'sYour Date of Birth: •
|
|
|
Student'sYour Gender: •
|
|
|
Country: •
|
|
|
Street Address: •
|
|
|
City: •
|
|
|
State/Province/County: •
|
|
|
State: •
|
|
|
ZIP/Postal Code: •
|
|
|
Primary Phone (including country code): •
|
|
|
Alternate Phone:
|
|
|
Email Address: •
|
|
|
Do you know someone who has attended a Wellspring program? •
|
|
|
|
Which of these best describes you? •
|
|
|
|
|
Student'sYour Weight:
|
|
|
Student'sYour Height:
|
|
|
What prompted you to contact us today?
|
|
|
What else have you (or has your child) tried to
lose weight?
|
|
|
How long were you (or your child) able to keep
weight off with any of the other solutions you’ve tried?
|
|
|
Have you considered bariatric surgery or other medical interventions to lose weight (or for your child to lose weight)?
|
|
|
|
Do any of these apply to you?
|
|
|
How did you hear about us?
|
|
|
Best day to call:
|
|
|
Best time to call:
|
|
|
If a person referred you, please tell us their name:
|
|
|
Please briefly describe the issues or problems that are causing you concern:
|
|
|
|
|
Wellspring's counselors, researchers and behavioral coaches are typically most helpful
if they know as much as possible about your situation. All information remains strictly
confidential.
|
|
|
|
|
|