The Reset Ritual Intake Form

The Virtual Reset Ritual

Fast to Slow Down
We’re so excited to host you for this at-home virtual retreat experience. From the comfort of your own space, you’ll be guided through the same powerful journey as our in-person Reset Ritual—designed to transform your relationship with food, health, and self-care.

Through this experience, you’ll learn how to cultivate effortless motivation and treat your body and food with reverence.

Your Virtual Reset Ritual Includes:
- The Reset Ritual Virtual Prep Course
- Extensive resources to help you understand how and when to fast effectively
- Ritual practices to set you up for your greatest success
- Peer support throughout the experience
- Nourishing recipes inspired by longevity science
- Four weekly zoom meetings
- Support to make healthy habits feel natural
- Tools to reset your metabolism and detox your body safely
- Opportunities to reconnect with your intuition and build trust in your body’s innate wisdom
- A total-body cellular reset—physically, mentally, and emotionally
Basic Information

All information will be kept confidential.
Legal Name
Preferred name
Occupation
Phone Number
Email
example@example.com
Body Mass Index Screening

All information is confidential
Weight in lbs
Height
In inches
Age
FemaleMaleOther
PregnantBreastfeedingNeither
Goals and intentions

Let us know whats motivating you to join this experience.
Personal growthGut HealthReset Eating PatternsAnti-AgingRight of PassageWeight Loss or improve metabolic healthAuto-Immune HealthReconnect with nature / spiritStart a connection with nature / spiritImproving skin conditionsReversing Brain fog/ cognitive healthReverse fatigue or symptoms of low energy.Other
In your own words, what's your primary intention for joining this experience?
Skin conditionsFatigueBrain fogWeight managementInflammationMetabolic healthCancer or other Serious conditionOther
In your own words, what signs of health or symptoms of disease do you notice in your body?Include anything you've observed—this could be physical, mental, or emotional. Examples might include: acne, weight gain, trouble building muscle, anxiety, difficulty focusing, poor sleep patterns (circadian rhythm), or anything else you've experienced.
Current medications
Please list any Rx medications.
Relationship with Food & Nourishment

Wherever you are on the spectrum of self care, we always have room to improve.
90% or more of my meals are homemade.50% or more of my meals are homemade.50% or less of my meals are homemade. Majority of my meals are outsourced.I don't cook for myself. The vast majority of my meals are outsourced to professionals.
Do you have a history with disordered eating (anorexia, bulimia, etc.) If so, please describe below.
Include history, any current conditions, and any treatments statuses. If not applicable leave, NA.
How do you feel your relationship with food could be better? Please describe below.
Our relationship with food is one of the major foundations of our life, whether you regularly address this variable of a happy life or have never thought of it all, we all have room to improve with self nourishment.
Previous Experience

Fasting, communal retreats, and trauma healing.
Never fasted1-2 fasts3+ fasts completedAnnual practices fast 1 - 2 times a year.Other
Less than 2 times a week I practice IF.3-5 times per week, I'm a bit of an IF pro.I practice IF every day.I've done it a handful of times but I've not done it consistently"I'm not sure what intermittent fasting is."
What shadows, subconscious behaviors, or personal challenges are you aware of in yourself that you're working on in this chapter of life?
We want to start to get to know you on this deeper level so that we can support you holistically.
Is there anything else that you'd like to share with us?
How did you learn about the Virtual Reset Ritual?
Special Offer for This Cohort Only:
The Virtual Reset Ritual is offering an exclusive $200 discount for this summer’s cohort. Instead of the regular price of $600, you’ll pay only $400. This special pricing is only available to participants in this round of the Virtual Reset Ritual. Those who have paid and applied before July 7th.
Yes, I already sent the discounted $400, Venmo @Jerry-LaBonteI will, send the sweet discounted price of $400 shortly, Venmo@Jerry-LaBonteI'm special or in a special situation and want to ask for a discount. Contact me via the information provided above to discuss. (phone number or email).
Thank you for making time to apply!

We'll contact you with next steps or any additional questions.
Should be Empty:

The Virtual Reset Ritual

Basic Information

Body Mass Index Screening

Goals and intentions

Relationship with Food & Nourishment

Previous Experience

Thank you for making time to apply!