Today's date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20162017201820192020 Name * Street address Zip code Email address * Phone number What brings you to Suppers? (Check all that apply.) * I want to learn how to prepare delicious, healthy food and/or find recipes I want to develop a palate for healthy food I have a diagnosis I would like to improve or turn around I experience some of the problems or symptoms associated with low blood sugar or poor mood chemistry (e.g. depression, fatigue, cravings, poor concentration, etc.) I would like to be less dependent on medications I want to lose weight I have a professional interest I'm concerned with the health of a loved one and have come to support him/her I need support in living according to my intentions Other (please specify below) What are your other reasons for participating (if you checked "other" above)? How did you hear about Suppers? * Community outreach program Educational workshop Friend or family member e-Newsletter Purple Apron Press (print newsletter) Practitioner referral Social media Web site Advertisement Other (specify below) Please specify your "other" response (if you checked "other" above). Which topics interest you? (Check all that apply.) * Alzheimer's/Dementia Arthritis Bone loss Blood sugar Brain health/Brain fog Cancer Celiac disease Concerns for loved one Cooking Depression/anxiety/mood Digestive Health Emotional eating Fatigue Fermentation Food allergies/sensitivities Food addiction/cravings High blood pressure High cholesterol Immune support Parenting Recovery Thyroid/endocrine issues Weight management Women's health Other (please specify below) What other topics interest you (if you checked "other" above)? How would you describe your style of eating? Gluten free Low carb Macrobiotic Omnivore Paleo Raw vegan Vegan Vegetarian What time of day are you generally available for events? (Check all that apply.) Breakfast Lunch Dinner Weekdays Weekends How many people depend on you for meals, including yourself? What would you most like to accomplish in this program?