Thank you for your interest in our program. Please take this short survey to help us determine if the Balanced You program is right for you.Name *FirstLastEmail *Phone *What is your age? *Are you an existing patient at ERCA? *YesNoDo you have any medical conditions? *DiabetesHTNHeart DiseaseEating DisorderOtherCheck all that applyIf you checked "other" please list your medical condition(s)Are you currently on any medications? *YesNoIf so do they need to be taken with food? *YesNoDo you have any experience with fasting? *YesNoHave you read either "Delay, Don’t Deny" by Gin Stephens or "The Obesity Code" by Dr. Jason Fung, M.D.? *YesNoDo you want to try the program but don’t wish to fast? *YesNoCan you commit to 2 treatments per week ( allow for 20-30 minutes)? *YesNoIs there any thing else we should know about your medical history? *EmailSubmit