Health & Wellness Coaching Interest Form

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Thank you for your interest in the Health & Wellness Coaching program that we are building at Zero Breast Cancer! This form is for people who may be interested in participating. There is an option to join the waitlist at the end. 

Learn more about Health & Wellness Coaching here. Our program will be designed to reduce the risk of breast cancer in people at higher risk and reduce the risk of recurrence in survivors post-treatment. Going through the program will also help improve overall health and wellness, and reduce the risk of many other diseases. We plan to pilot the program in March 2024 and offer services before the end of the year. By filling out this form, you will help shape the program and can join a waitlist to be part of the pilot or receive services once the program is developed. We will be offering sessions remotely and look forward to serving people across the U.S. If you have any questions, please contact Program Director Lianna Hartmour at liannah@zerobreastcancer.org.
Which best describes you? Select all that apply.
We will begin by offering services 1:1 in individual sessions but may develop small groups in the future. Would you be interested in receiving services 1:1 or in a small group? Select all that apply
What is your likely availability to receive services over Zoom? Select all that apply. 
What is your Time Zone?
We plan to work with people who would like to develop and work toward goals in the following areas. Which are you most interested in? Select all that apply.
The program will last approximately three months. How often would you be interested in meeting? Select all that apply.
How long would you like sessions to be? Select all that apply.
Depending on our funding success, we may be offering services on a sliding scale for those who can afford it where people with lower incomes receive services for free or low cost and people at higher incomes pay more. Would you be willing to pay for services?
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