Wellspring Women's Program

Wellspring Women's Program Information Package

We would love to send you an Information Package and Brochure about Wellspring Women's Program - just fill out the form below!

If you have questions you'd like answered right away, please call us at 866.364.0808, or Chat Now

Wellspring Women's Program Information Package We would love to send you an Information Package and Brochure about Wellspring Women's Program - just fill out the form below! If you have questions you'd like answered right away, please call us at 866.364.0808, or Chat Now
Required fields are indicated by a • All information remains strictly confidential.
Which camp are you interested in? •
Your First Name: •
Your Last Name: •
Who is Inquiring: •
Camper's First Name: •
Camper's Last Name: •
Camper'sYour Date of Birth: •
Camper'sYour Gender: •	MaleFemale
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? •
YesNo
Which of these best describes you? •
I am considering attending Wellspring this summer (or sending my child to camp), but HAVE NOT reviewed Dates & Rates information. I HAVE reviewed the Dates & Rates information and hope to attend Wellspring (or send my child to camp) this summer. I cannot attend (or send my child) this summer, but would still like to learn more about Wellspring Camps.

Camper'sYour Weight:
Camper'sYour Height:
What prompted you to contact us today?
Recent weight gain Doctor's advice Medical concern An issue at school Depressed / withdrawn Other
What else have you (or has your child) tried to lose weight?
Gym membership Personal trainer Team sports Weight Watchers Dieting None of these
How long were you (or your child) able to keep weight off with any of the other solutions you’ve tried?
Less than a month 1 to 6 months 6 months to a year More than a year Weight was never lost with other methods No other methods have been tried
Have you considered bariatric surgery or other medical interventions to lose weight (or for your child to lose weight)?
YesNo
Do any of these apply to you?
Unhappy or depressed because of weight Withdrawn from friends and social situations Diagnosed with pre-diabetes, Type II Diabetes, or some other medical condition associated with being overweight Not living up to potential at school None of the above
How did you hear about us?
Best day to call:	WeekdayWeekend
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:

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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.