Ready to take control of your health?

(262) 993-4857

Ready to take control of your health?

You’re here because you’re ready for a change — and we’re here to help you make it happen.

At UpLevel Wellness, we believe lasting health isn’t about quick fixes; it’s about creating a lifestyle that works for you. To make the most of our time together, take a moment to fill out this quick form. This helps us understand your goals, challenges, and what support you need to thrive.

We can’t wait to connect and see how we can help you elevate your health and life!

Share your current reality

First Name *

Last Name *

Email *

Phone *

SMS Authorization

I agree to receive reminders & updates via text message. I can opt-out at any time by replying STOP

Who referred you? *

If you selected other, please share how you found us!

Right now, how would you describe your overall health? Physical, mental, energy, self-confidence, etc. *

Why do you want to lose weight? What do you think will be different in your life when you get to a healthy weight? *

What would your dream health/weight look like? *

What would you change about your life right now to make it better? (Please know this is confidential. Share away, it's amazing what can change when we get our health in check.)

Are you pregnant or nursing? *

What is your current age? *

How tall are you? *

What is your current weight? *

How many pounds away are you from feeling confident? *

Have you tried other programs to lose weight or get healthy before? Why or why not do you believe they were successful?

Briefly describe your average day of eating. How many times do you eat? Are you planning head or grabbing whatever is available? Please include both meals and snacks.

On average, about how many ounces of water do you drink a day?

How would you describe your motion and exercise habits currently?

Are you currently participating in a medically supported weight loss program? Or is this something you have considered?

On a scale of 1-10, how committed are you to getting to your health goals?

If we match you with a program you love and you see the results you are looking for, would you be interested in learning more about helping others with their health while also earning a great income? *