ReviveWell Founding Cohort — Application
Please complete this application honestly and in full so we can review your fit for the cohort.
About You
Full Name
*
First Name
Last Name
Email address
*
example@example.com
Mobile phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
How did you hear about the cohort?
*
Please Select
Existing client / patient
Referred by a friend or provider
Instagram
TikTok
Podcast / interview
Email from ReviveWell
Google search
Other
If referred, by whom?
What Brings You Here
Which pillars are most important to you right now?
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Gut health (digestion, bloating, microbiome, food sensitivities)
Sleep (depth, duration, recovery, insomnia)
Energy (fatigue, brain fog, mitochondrial function)
Metabolic health / weight (GLP-1 interest, body comp)
Hormones (perimenopause, andropause, thyroid, cortisol)
Longevity / performance optimization (NAD+, glutathione)
In your own words, what's bringing you to the cohort now?
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If we worked together for 6–12 months, what would make this a clear success for you?
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How would you rate your overall energy/wellness right now?
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Struggling daily
1
2
3
4
5
6
7
8
9
Thriving
10
1 is Struggling daily, 10 is Thriving
Health Context
Have you had recent labs done (in the last 12 months)?
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Yes — comprehensive functional panel
Yes — but only basic / annual physical labs
No
Have you used any of these before?
GLP-1 medications (semaglutide, tirzepatide)
NAD+ (IV, IM, or oral)
Glutathione (IV, IM, or oral)
Other peptides (BPC-157, TB-500, sermorelin, etc.)
Bioidentical hormone therapy
Functional medicine practitioner
None of the above
Logistics & Commitment
Investment readiness
*
Ready to invest at this level if accepted
Open to a payment plan to make it work
Exploring fit, not yet decided
Can you commit to 6 months (minimum)?
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Yes
Most weeks — some travel/work conflicts
Unsure
Anything else we should know?
Consent
*
I understand this application does not guarantee acceptance, and that the program is a wellness service — not a substitute for emergency or primary medical care.
Submit Application
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