Self Healed System Application
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
How would you describe your current health and wellness overall?
Very good
Good
Fair
Poor
I'm not sure
What areas of your health feel most challenging right now? (Select all that apply)
*
Weight & Metabolism
Energy & fatigue
Hormones / Menopause
Digestion / bloating
Inflammation or pain
Stress / sleep
General uncertainty about my Health
Understand lab results
How did you hear about the Self-Health System
*
Referral
Meetup
Blood work appointment
Website
Social Media
Google
Other
Back
Next
What prompted you to explore wellness support at this time?
*
Age Range
*
Please Select
18-24
25-34
35-44
45-54
55-64
65+
What have you already tried to address these concerns
Have you had blood work done within the past 6 months?
*
Yes
No
Not Sure
On a scale of 1–5, how confident do you feel understanding your lab results and applying them to improve your health?
*
1
2
3
4
5
What do you feel has been missing from your past healthcare or wellness experiences?
*
If nothing changes in the next 6-12 months, how do you thing your health may be affected?
What would feeling supported and clear about your health look like for you?
*
What kind of support are you hoping to receive right now?
*
Education and clarity
Accountability and structure
Help understanding labs
Long-term guidance
I'm not sure yet.
The Self-Healed System is designed for individuals who want to understand their labs, take ownership of their health, and implement sustainable changes — not quick fixes. Does this align with what you’re looking for?
*
Yes
Possible - i'd like more information
No
If accepted into the Self-Healed System, are you prepared to invest in ongoing, personalized wellness support?
*
Yes
Possible
Not at this time
Are you comfortable with 100% virtual, 1-on-1 meetings?
*
Yes
No
This program involves reviewing blood work and learning how to understand your results. Are you open to lab-guided education?
*
Yes
No
The Self-Healed System is a paid, private program. If approved, are you open to making a financial investment in your health?
*
Yes
Possibly
No
Coaching sessions are offered virtually Monday–Friday at 8:30 AM, 12:30 PM, or 5:30 PM Eastern Time (ET).
*
I acknowledge that all sessions are scheduled in Eastern Time and confirm my availability within these hours.
Is there anything else you’d like me to know about your health journey or goals?
*
Submit
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