Consult Application Form

PRISM Clinical Strategy Application

This application helps determine whether this work is a goodfit and what level of support may be most helpful. Because I work with alimited number of clients at a time, all applications are personally reviewed.You will always receive a response.Estimated time: about 10 minutes.
Name*

First NameLast Name
Date of birth:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Which program are you most interested in?

PRISM Clinical Strategy Review (one-time review) $297PRISM Clinical Strategy Intensive (30 days) $750PRISM Clinical Strategy Partnership 3 Month $2,500PRISM Clinical Strategy Partnership 6 month $5,000
After reviewing your application I will always recommend the level of support that makes the most sense for your situation. You are never required to start at a specific level.

If for some reason thee is a better option for you, I will let you know that too.
If accepted, are you prepared to make this investment?

YesI have questions before committing
What are your top 3 current challenges or symptoms?*
On a scale of 1–10, how frustrated are you with how you currently feel?
Are you currently working with a healthcare provider for any of these challenges?

YesNo
Have you had any lab testing in the past year?

YesNo
What have you already tried?

SupplementsHormone therapyGLP-1 medicationDiet changesExercise programsFunctional medicineOnline programsOther
What were you hoping these would help you with?
Of the things you tried, what helped and what didn't?
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 made you seek help now rather than continuing on your own?
What best describes your readiness to implement structured recommendations?

I am ready to implement changes consistentlyI am ready, but anticipate needing guidance and accountabilityI am still deciding if this is the right time
Are you currently on any prescription hormones?*

YesNo
Any major health conditions you feel are important to mention?
What would you say your current level of stress is?

LowMediumHighOut of control!
How would you describe your sleep?
Is there anything else you would like me to know about you?
When are you hoping to begin?

Within the next 2 weeksWithin the next monthLater 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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PRISM Clinical Strategy Application