Full Name

Email Address

Would you like your email added to our mailing list? Would you like your email added to our mailing list?Yes! I would like to receive periodic updates and tips.No, thank you. I prefer to only receive emails regarding my appointment, orders, or account.

Phone Number

May we text you on this number? May we text you on this number?Yes, I would like to receive relevant texts at this number.Yes, but only for appointment notifications.No texts, please.

Marital Status Marital Status Single Married Divorced

Is your spouse willing to attend the initial appointment? Is your spouse willing to attend the initial appointment?Yes, I understand my spouse must attend.No, my spouse will not be able to attend (appointment may be subject to cancellation).

Which area of your life do you feel is your greatest strength? Why?

Which area of your life do you consider is your weakest? Why?

What is the #1 most important thing for you to change in yourself?

How much is it costing you every day that you do not change?

If you could have absolutely any 3 wishes granted right now, what would they be?

Why must you be chosen to participate in this program?

What might get in the way of your commitment to change?

If we decide that we are a good fit for each other, there will be a financial commitment for the program. If we decide that we are a good fit for each other, there will be a financial commitment for the program.I am all in and ready to change my life!I am going to wait and see how much worse it can get.