Mind and Body Makeover VIP Application

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What is your full name?* This field is required.
First Name
Last Name
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What is your best email address?* This field is required.
example@example.com
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Are you motivated and committed to achieving results and finally reaching your weight or fitness goals? * This field is required.Select ONE (1)
Yes -100%Maybe, not sure. . . sorta!
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What is it that motivates you? * This field is required.Select all that apply
My confidence will go up!
I have an event this year, and I want to look smokin'
I want to be healthy for my kids/family
I have a medical condition that will improve if I lose weight.
I want to be able to shop anywhere and wear cute outfits.
I seriously need to get bathing suit ready
I feel tired and sluggish
I'm doing this for ME and me alone
Other
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Do you have any health conditions that prevent you from exercising?* This field is required.
YESNO
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So tell me, which of these have you tried? Select ALL that apply. This will help me understand the journey you have been through so that we can avoid future pitfalls. If you haven't tried any of these, you can skip this question.
Cutting Carbs
Keto or Paleo diets
Weight Watchers
Home delivery of diet foods
Shakes
"Magic" pills that promised to work
Noom (or similar apps)
Gym membership or home gym equipment
Cutting calories
Eating more protein
Intermittent fasting
Other
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Please rate on the scale truthfully (1=Poor to 10=Excellent)The lower the score would indicate areas that you are suffering with the most.
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Overall energy levels
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Overall energy levels
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If you had 3 wishes for your dream body, lifestyle or fitness level, what would they be? Example: I wish I was 20 lbs. lighter, I wish I was more toned, I wish I had more energy, I wish I knew how to eat healthier without feeling hungry . . .
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How soon would you like to reach your goal and have these wishes be a reality?
In the next 30 days
In the next 90 days
In the next 6 months
In the next year
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Let's pretend you have worked with me for the past 12 weeks, what results would you have that would make you ecstatic?!
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The investment for the VIP experience starts at $4797 if paid in full, or you can select a payment plan below. Which of these would work best for you?* This field is required.This will not be final until your application is approved and you are in the program, so you can always choose a different option later if you need to.
Pay in full- $4797
3 Monthly Payments of $1700
2 Equal payments of $2500
I'm not able to invest that much, but I'd love other options
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If this is a good fit and move forward, your 12 week VIP with me will start on the date that we confirm together. Prior to that start date, I will need a few key things from you that will allow us to effectively track your before and after, so that you can continue your success even after our time together. Are you good with that plan?
YES- Of course! No, I'm not that committed
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Before you hit the send button, do you have any questions or comments that you would like to share? If not, go ahead and hit the send button!
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