Full Name
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First Name
Last Name
Email
*
example@example.com
Country Code & Mobile Number
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Age
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Before you got sick, briefly describe your typical daily activities and energy levels
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What do you feel you need help with the most?
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If we helped you over the next six months to improve your health and wellbeing, what are three goals you would love to be able to achieve in that time?
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On a scale of 1–10. 1 being low and 10 being very high, how committed are you to improving your health right now?
Which of these have you tried already?
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Please Select
Brain retraining
Supplements / Medication
Doctors and medical route
Alternative therapies
All of the above
We believe that a holistic integrative approach is required to achieve results and recovery. Quality sleep, routine & structure, baseline, nutrition, mindset, progression and self responsibility all play a role. With the right help, tools, frameworks and education, are you committed to working on different areas of your health and well-being to obtain the results you want?
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Please Select
Yes
No
How much money have you spent so far on trying to solve this issue?
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Please Select
$0 - $500
$500-$3000
$3000 - $10,000
$10,000 to $30,000
$ 50,000 Plus
Is this an important enough priority that you can allocate (or find) the financial resources toward a solution if you knew it would help you get better?
*
Please Select
A. I’m not in a position where I can spend anything on my health.
B. I’m committed and willing to invest, but can only afford $100-$200/week.
C. I’m so sick of being unwell and I'm looking for long-lasting results so I no longer have to think about recovery. I'm willing to spend $10k + on something that gets me better.
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