Form
Application for 1:1 Coaching with Dr. Leott
Name
*
First Name
Last Name
Date of birth:
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Which program are you most interested in?
Clarity Intensive One Time Consult($600)
3 Month Guided Clinical Reset($1,350)
If accepted, are you prepared to make this investment?
Yes
I have questions before committing
What are your top 3 current challenges or symptoms?
*
What have you already tried?
Are you currently working with a medical provider for menopause/perimenopause/weight management?
*
What would make this successful for you? What result are you hoping for?
*
Why is now the right time to invest in your health?
What best describes your readiness to implement structured recommendations?
I am ready to implement changes consistently
I am ready, but anticipate needing guidance and accountability
I am still deciding if this is the right time
Are you currently on any prescription hormones?
*
Yes
No
If yes, please list them here.
Any major health conditions?
*
What would you say your current level of stress is?
Low
Medium
High
Out of control!
How would you describe your sleep?
Is there anything else you would like me to know about you and your journey?
When are you hoping to begin?
Within the next 2 weeks
Within the next month
Later this year
Please read and accept the following:
*
I understand this is an application and does not guarantee acceptance into a program.
I understand Dr. Leott provides consulting, not primary medical care. Prescriptions are determined by my provider.
Services provided include lab interpretation and structured guidance. No medical diagnosis or prescription is provided. I will continue care with my licensed medical provider.
I confirm that the information provided above is accurate to the best of my knowledge, and I understand that recommendations are based on the information I provide.
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