The Joules Method
Application Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Birthdate
-
Month
-
Day
Year
Date
Marital Status
Please Select
Married
Unmarried
It’s complicated
Divorced
What goals do you hope to achieve with the Joules Method?
Mind-Gut symbiosis
Heart-brain coherence
Manifestation & energetic alignment
Create sustainable, healthy daily habits
Rebuild my relationship with food
Rebuild my relationship with myself
Gain effective tools for coping with stress
All of the above
Other
What other modalities have you explored to reach your goals?
For the areas that haven’t been as successful, why do you think those modalities didn’t work?
On a scale of 0-10, how coachable are you? 10 being extremely coachable.
Do you consider yourself a perfectionist?
Please Select
Yes
No
Please list your top 3 limitations keeping you from reaching your goals.
Why is now a good time?
Are you prepared to invest in yourself for a deep transformation of body and mind?
Please Select
Yes
No
Just curious
Do you have any current health problems?
Do you follow any religious or spiritual practices? If so, please describe briefly.
Please add any further thoughts or information you think may be helpful or relevant in any way.
Submit
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