become herThe Mom Method
The Mom Method · Become Her

Client intake form & programme agreement

Please complete this form before the programme begins. You may ask to discuss a sensitive answer privately.

Your details

Getting to know you

What made you interested in The MOM Method: Become Her? *
What would you most like to understand or change in your relationship with food, your body, or yourself? *
In what situations do you notice patterns around food? (For example: stress, overwhelm, loneliness, restriction, guilt, or feeling out of control.)
How do you usually speak to yourself when things do not go to plan?
What have you tried before, and what felt helpful or unhelpful?
What would progress look like over the next 90 days, apart from a number on the scale?
What might make it difficult to participate consistently, and what support would help?
On a scale of 1–10, how ready do you feel to take part and practise between sessions? *
Why did you choose that number?

Support & suitability

Are you currently receiving support from a doctor, psychologist, psychotherapist, psychiatrist, dietitian, or another qualified professional for your physical health, mental health, or relationship with food? *
If yes, type of support (optional)
Have you been diagnosed with, or are you currently experiencing, an eating disorder or symptoms such as recurring binge episodes, purging, severe restriction, or intense fear around food/weight? *
Is there anything about your health, safety, or circumstances that may mean you need specialist support before or alongside this programme? *

You do not need to give details here.

Do you understand this is coaching/education, not therapy, medical care, or eating-disorder treatment? *

Your commitment

Please read and tick each statement.

Programme terms & conditions

  1. What the programme is. The MOM Method: Become Her is a 90-day coaching and educational programme focused on awareness of food-related behaviours and patterns, self-trust, habits, self-respect, and personal development. It is not a diet plan, nutrition prescription, psychotherapy, counselling, medical service, or treatment for an eating disorder.
  2. Professional boundaries. Daphne is not a therapist, psychologist, psychiatrist, doctor, registered dietitian, or eating-disorder specialist. The programme does not diagnose or treat mental-health conditions or eating disorders and does not replace care from a qualified professional. Materials are educational and are not individual medical advice.
  3. Suitability and additional support. You agree to answer the suitability questions honestly and tell Daphne if your circumstances or support needs change. If your needs fall outside the programme's scope, you may be advised to seek qualified healthcare support before or alongside participation. Do not stop prescribed treatment or professional support because of this programme. Participation may be paused or declined if specialist support is needed for safety or suitability.
  4. Other diets or food programmes. The MOM Method is not a diet. During the programme, you agree not to start or follow a separate restrictive diet, weight-loss challenge, or competing food programme that conflicts with this work. This does not mean stopping medically necessary nutrition guidance or treatment. Discuss any changes with your qualified healthcare professional and tell Daphne if you are receiving such care.
  5. Participation and weekly calls. You are responsible for your choices and for applying the material appropriately. You agree to engage with exercises and reflections and attend a weekly one-to-one call on Monday or Tuesday at a mutually agreed time. If you can't make your weekly call, let me know at least 2 hours before. Without 2 hours' notice, the call is missed and we meet again the following week.
  6. Payments and refunds. All programme payments are non-refundable. Please make sure you understand the programme and are comfortable with your commitment before enrolling. This policy does not remove any consumer rights that cannot legally be excluded.
  7. No guaranteed results. Individual experiences and results vary. No specific change in weight, eating behaviour, confidence, or other outcome is guaranteed. The programme provides education, reflection, coaching support, and accountability.
  8. Communication, confidentiality and emergencies. You agree to communicate respectfully and not share other participants' personal information in the group chat. Messages are not an emergency service and may not be answered immediately. If you are in immediate danger or need urgent mental-health support, contact local emergency services (112 in Malta) or an appropriate crisis/health professional.

Your privacy

Your answers are private. Only Daphne can read them, and they are used only to support you in this programme. Some answers are about your health, so they are stored securely and never shared or sold. They are kept for the length of the programme and up to 12 months after, then deleted. You can ask Daphne at any time to see, correct or delete your answers. Only answer what you are comfortable sharing — you can always choose "Prefer to discuss privately".

Acknowledgement & signature

Signed today, 15 October 2026.

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