Application_Template

First Name

Last Name

Preferred Name (if different than first name)

Phone Number

Age

Gender

Address

Address Line 2

City

State

Zip Code

How did you find me?

What prompted you to apply for a discovery call right now? (What feels hardest, most frustrating, or most urgent at this stage?)

How are these symptoms affecting your daily life? (Work, relationships, confidence, enjoyment, or sense of self.)

What have you already tried to manage or improve your symptoms? (Lifestyle changes, supplements, medications, HRT, stress management, exercise, etc.)

What has helped—even slightly? What hasn’t worked or felt sustainable?

If we could wave a magic wand and help you feel your absolute best this year (physically, mentally, and emotionally) what would that look like for you?

What kind of support are you most interested in right now?

Education about what’s happening in my body

Lifestyle-based strategies (sleep, nutrition, movement, stress)

Personalized guidance and structure

Accountability and ongoing support

Not sure yet

Do you know we operate as a concierge service (no insurance billing, high-touch care model)?

Yes

No, I'd like to learn more

The commitment to work together in a high-level 1:1 relationship requires both a financial and time investment. Are you able and willing to make both the time and monetary investment in yourself?

Yes, I’m ready to invest in the right support if it’s a good fit!

I’m not sure if I am able to invest at this time, even if it feels like a good fit.

I’m not ready to invest at this time.

What concerns or obstacles might make it difficult for you to move forward right now? (Time, energy, finances, overwhelm, uncertainty, support at home, etc.)

Is there anything else you’d like me to know before our call? (Questions, fears, hopes, or context you want to share.)

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