VIP Concierge Program Application

1
Please tell us your name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
What state and country do you currently live in?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
6
How did you hear about us?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
7
Have you worked with a Nutritionist in the past? If so, what was your experience like?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
8
What are your top 3-5 health concerns and goals?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
9
Have you had any recent labs done in the last three months? If so, please list what testing below.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
10
What do you feel most sets you back from achieving your health goals?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
Please describe a typical day of eating (include all meals, snacks and beverages).* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
What interests you most about The CLW VIP Concierge Program?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
If we were to work together for 12 months, what would success with this program look like for you?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
14
On a scale of 1-10, how committed are you to making nutritional and or lifestyle changes?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
15
The CLW VIP Concierge ProgramIncludes one full year of concierge level support: 14 one on one video sessions with Courtney, six functional lab tests throughout the year to track your progress ($4,000 + value), nutrition coaching, subconscious reprogramming, personalized care plans and supplement protocols based on your lab test results, peptide coaching when/if needed, customized recipes and meal plans. BONUSES: 1 functional lab test plus one hour follow up and care plan for any one member of your immediate family ($1300 value), 1 year free of the CLW Membership ($495 value), Weekend Retreat in Naples, FL ($2,000 value).
Pay in full $18K (save $2K).
Payment Plan Option: $5K deposit and then $1250/month for twelve consecutive months.
I am in, not sure what payment option yet.
Should be Empty: