Discovery Call Application with Czarina

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Date of Birth* This field is required.

4

Phone Number* This field is required.

Area Code

Phone Number

5

City, State* This field is required.

6

What's your biggest symptom right now?* This field is required.Choose the one affecting your daily life the most.

Sleep disruption / waking up at 3am

Brain fog / memory issues

Anxiety or mood swings

Belly fat / weight gain

Fatigue / low energy

Hot flashes / night sweats

Sexual health changes

Other

7

How long have you been experiencing these symptoms?* This field is required.

Less than 3 months

3-12 months

1-3 years

3+ years

8

Have you spoken to a healthcare provider about your symptoms?* This field is required.

Yes, and I felt heard and supported

Yes, but I felt dismissed or wasn't given real answers

No, I haven't brought it up yet

No, I don't currently have a provider

9

What have you already tried to address your symptoms?* This field is required.Select all that apply.

Lifestyle changes (sleep, diet, exercise)

Supplements

Prescription medications or hormone replacement therapy (HRT)

Therapy or mental health support

Nothing yet - I'm just starting to research

Other

10

What would feel like a win for you 3 months from now?* This field is required.Be as specific as you'd like.

11

Which of the following best describes where you are right now?* This field is required.Be honest - there's no wrong answer.

I'm ready to invest in my health and looking for the right support

I'm interested but need more information before deciding

I'm not sure I can afford support right now

I'm just exploring — not ready to commit to anything

12

What's your investment range for support right now?* This field is required.This helps me recommend the right level of support for your situation.

Under $200 (digital courses and guides)

$200–$600 (testing and consultations)

$600–$2,000 (comprehensive packages)

$2,000+ (full clinical care and hormone management)

13

Is there anything else you'd like me to know before our call?Optional — but anything you share helps me prepare.