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

State* This field is required.

4

Occupation (this group is not for other acupuncturists)* This field is required.

5

Brief Description of Your Condition* This field is required.

Diagnoses and/or main signs and symptoms

7

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

8

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

9

List everything you've tried for this condition thus far* This field is required.

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

10

What are some of your biggest challenges to healing right now? Please describe how you'd like this program to help you specifically* This field is required.

11

Please share something you believe to be true about your current health situation that may be controversial or that others don't necessarily understand

12

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.

13

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

14

How did you find this program? 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.

15

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