New Client Registration Form BRAVE Group Course

New Client Application - BRAVE 20 week guided transformation.
Full Name*

First NameLast Name
Address
City, State
Phone Number*
E-mail
example@example.com
Date of Birth

MonthDayYear
Date

Your Cancer Journey
What type of cancer were you diagnosed with?
When were you diagnosed?
When did you complete treatment and what type? (Month/Year)
Are you currently in remission? (Yes/No/Other – please explain)
Do you have any ongoing side effects from treatment? (Fatigue, neuropathy, limited mobility, etc.)

Your Current Physical & Emotional State
How would you describe your current physical strength and energy levels?(1 = very weak, 10 = very strong)
What are your biggest struggles right now in rebuilding your body and confidence?
Have you tried any exercise, movement, or recovery programs since treatment? (If yes, what worked/didn’t work?)
On a scale of 1-10, how confident do you feel in your body right now?

Your Commitment & Goals
What do you hope to achieve by the end of this 5-month course?
Are you able to commit to watching short videos and joining weekly group calls? (Yes/No)
Do you have any specific concerns or fears about joining the course?
On a scale of 1-10, how willing are you to step outside your comfort zone to create real change?
What excites you most about this program?

Final Steps
How did you hear about BRAVE?
Is there anything else you’d like me to know before we get started?
This is a paid program that requires an investment in yourself. Are you financially prepared to join? (Yes, I'm ready / I’d like to discuss payment options / No, but I’d love support in the future)

Client Commitment
**Commitment Statement:**

I am committed to fully engaging in the BRAVE program to rebuild and elevate my life. I understand that my coach is here to support and guide me, but my progress depends on my own dedication and action. I take full responsibility for showing up, implementing the steps, and embracing this journey toward strength and confidence.
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