Synthesis Health PRO Group Application (Guest)

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What is your professional background?* This field is required.Please share your profession, whether you're licensed, and what type of medicine you practice
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What country do you live in?* This field is required.
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What's your name?* This field is required.
First Name
Last Name
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What prior training have you done?* This field is required.Degree and continuing education in the Chinese Medicine, Functional Medicine, herbs, bodywork, etc
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Please describe how you would like us to help you specifically with your clinical skills?* This field is required.Be as detailed and specific as possible
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If we were sitting down and talking a year from now, what would have needed to change for you to feel successful with your practice?* This field is required.
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If your application is successful, what is the best way to let you know?* This field is required.You can choose more than one method
Signal
Facebook Messenger
Email
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What is the link to your Facebook profile?So we can make sure we have the right person when we let you know your application status via FB messenger (we will not contact you for any other reason) You can find your link by going to your own profile page and copying the URL from the address bar there.
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What is your mobile phone number?* This field is required.This is very important so that we can recognize you in our SH group chat. We respect your privacy and do not call you, text you, or bother you in any capacity.
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Your favorite Email Address?* This field is required.So we can let you know your application status via email (we will not contact you for any other reason) Make sure you check your junk/spam/promotions folders in the next 24-48 hours
example@example.com
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Honestly, which best describes your attitude towards healing?* This field is required.
I am open and ready for new health solutions, and I believe there is a way for me to get better.
I am jaded and burned out from trying and failing, but still optimistic there's hope.
I'm just here to learn more
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How much are your symptoms interfering with your life?* This field is required.
My symptoms interfere significantly, but I still push through to have the fullest life possible
My symptoms interfere significantly and I've given up doing so many things that I used to enjoy
My symptoms are mild and rarely interfere with my life
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What is Your Age?* This field is required.You must be 18 or over to join our group. If under 18, your parent/guardian may apply on your behalf.
18 - 21
22 - 29
30 - 39
40 - 49
50+
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Where did you hear about Mel / Synthesis Health?* This field is required.If you were referred by a specific practitioner or colleague, please share their name. If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question
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Which of these symptoms do you regularly experience?* This field is required.Check all that apply
Fatigue/Exhaustion
Chronic Pain
Brain Fog
Sleep Trouble
Digestive Issues
Anxiety
Hormonal Issues
Depression
Inflammation
Weather Sensitivity
Headaches
Allergies
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Please describe how you would like us to help you specifically with your health?* This field is required.Be as detailed and specific as possible
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Please list everything you've tried in the past to improve your health, and how much each cost* This field is required.Practitioners, Programs, Courses, Retreats, Supplements, Products, etc
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What are some of your biggest challenges to healing right now?* This field is required.What's blocking you from getting better? If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question
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Please share something you believe to be true about your health that almost everyone else disagrees with you on?* This field is required.Be as detailed and specific as possible If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question
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If we were sitting down and talking a year from now, what would have needed to change for you to feel successful with your health?* This field is required.Be as detailed and specific as possible If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question
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If we could wave a magic wand and give you only one wish, which would you choose?* This field is required.
I would wish to have my symptoms go away 100% for a year, and then return as they were
I would wish for my symptoms to reduce by 50% and stay that way for the rest of my life
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Why did you choose that specific answer?* This field is required.Be as detailed as possible If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question
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Are there any unique factors we should know about you while considering your application?* This field is required.If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question
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This community is brand new, but I’m not and I have rules…

By joining this group you agree to all of the following.

1. Be nice. Seriously. There is no negativity of any kind (there are enough Facebook practitioner groups out there full of judgment, complaints and condescension). This is a proactive, solution focused group that looks for a positive way forward. Any nasty behavior (bullying, complaining, hostility, etc) is grounds for immediate removal. Removal is at my sole discretion.

2. Ask questions. Make your questions specific. In the interest of everyone reading the posts, please don’t ramble and tell stories. This is a solution focused group, and in order to help you solve problems, we need you to ask clear questions. If some background info is needed to frame the question then great please share it.

3. Share wins! When something positive happens for you as a result of something you’ve learned here (even if it is a tiny thing) absolutely share it with the group! And when you see someone’s wins, congratulate that person! We are working here to create virtuous cycles of positive feedback and higher standards.

4. Focus on the main thing which is developing mental models and effective strategies to improve your health and decrease your symptoms by 50% at a minimum while learning cutting edge skills to transform your clinical outcomes.

5. You are allowed to refer high quality people to this group only. Please just let us know who they are, why you’re referring them, and that you’ll vouch for them. No bad apples. See rule 1.

6. Confidentiality. Members of this group will be posting professional as well as personal information and sensitive stories. Keep everything in here confidential. (See NDA below). Guests and Members may not take screenshots or share content outside of the group. That being said, when I see a post/question/win that is especially inspiring, I may save and share it (protecting the privacy of all involved of course) as a means to share this work with others and let them know change is possible. If you post something that you absolutely do not want shared, even with your name removed, please tag it #noshare so that it’s clear. The onus for this is on you. If you have an issue with this it is up to you to contact me directly. Also despite my best efforts, I am not 100% perfect. If anything confidential ever leaves the group such as a name etc please let me know immediately and I’ll handle it.

7. While the Signal app is encrypted and very secure, we cannot control the security level within Signal. There is no HIPAA certified version of the app. We use the Signal platform for convenience and logistical ease of use. While Signal is a very established platform, there is always the remote possibility of a 3rd party data breach that is well out of our control, even with end-to-end encryption. There is always the possibility of a data breach of any of our other technological utilities, including the website, the Lab notes, email accounts, survey tools, etc. By participating in this platform you hereby agree to hold all parties harmless in the event of a data breach or HIPAA violation due to any of our technical channels being compromised.

8. No spam, links, promos, fundraisers, or memes. This is not the place for that as all of it goes counter to our main goal of asking questions, sharing wins, and improving your own health by 50% as well as improving your clinical confidence and outcomes.

9. To be clear, I am giving you information in good faith. It is up to you how you implement it. Becoming a guest or member of this group does not in any way imply that you and I have a patient-provider medical relationship. I am not your doctor. Discuss anything you’re thinking of implementing with your doctor beforehand. By entering this group you agree 100% to hold me harmless for any action you may take based on the information I provide.

Sound Fair?

If so, great. And welcome, I’m glad you’re here.

**Make sure you that you understand the Non-Disclosure Agreement (NDA) and sign below:**

On this day, I (the applicant) willfully join the Synthesis Health PROLab Mentorship Group by Synthesis Health Lab, Mel Hopper Koppelman, hereafter referred to as “the Company.”

As part of this relationship, I acknowledge that I will become privy to trade secrets, business practices, systems and other intellectual property (IP). I hereby declare that I will not disclose, sell, imitate, mimic, or otherwise share this information in any way that may be deemed detrimental or competitive towards the Company.

Additionally, due to the personal nature of this group I will become privy to other group members’ health and business information, personal information such as location and phone number, and finances may also be discussed to varying extents.

I hereby declare that I will not betray the confidence, harass, or exploit any of the other members of the group (including admins). Additionally I declare I will not disclose or sell any information regarding the members of the group (including admins).

I understand that my status as a member of this group may be revoked at any time.

I may renounce my status at any time. I agree to maintain confidentiality, discretion, and refrain from competing with the Company afterwards.

I understand that if I violate this agreement, legal action will be taken against me. If it is indeed found that I have violated the agreement, I shall be responsible not only for damages, but for all legal fees the Company may incur as a result of my actions.
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Do you agree to respect our Group Rules & Conditions (GRC)?* This field is required.
Yes!
Nope
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Do you agree to follow the terms of the Non-Disclosure Agreement (NDA) above?* This field is required.This protects the privacy of all group Guests and Members as well as my Intellectual Property
Yes!
Nope
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By signing below I agree to follow the group rules, abide by the terms of the Non-Disclosure Agreement (NDA) above and to complete my check in process within 72 hours once I've arrived. My answers on this form are accurate, true and honest; this form is complete and ready to be submitted to Mel.* This field is required.
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