The Idiosyncratic Group + Vault Application

1

Full Name* This field is required.

First Name

Last Name

2

Email Address* This field is required.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Location* This field is required.

5

Age* This field is required.

6

Occupation* This field is required.

7

Brief Description of Your Condition* This field is required.

Diagnoses and/or main signs and symptoms

9

What are your goals with joining this program?* This field is required.

10

What is your current attitude towards healing?* This field is required.

11

How much are your symptoms interfering with your life?* This field is required.

12

Please list everything you've tried to improve your health and a rough estimation of cost* This field is required.

Practitioners, programs, courses, retreats, supplements, products, etc.

13

Please describe how you'd like this program to help you specifically* This field is required.

14

What are some of your biggest challenges to healing right now?* This field is required.

15

Please share something you believe to be true about your current health situation that may be controversial or that others don't necessarily understand* This field is required.

16

If we were sitting down and talking a year from now, what would have needed to change for you to feel successful with your health?* This field is required.

17

Would you rather have 100% symptom relief for a year or 50% improvement for the rest of your life? Why?* This field is required.

18

How did you find this program?* This field is required.

19

Was there a specific video or post that resonated with you and made you want to apply? What was the title or topic?* This field is required.

20

Lastly, are there any unique factors we should know about your case while considering your application?