First Name *

Last Name *

Email *

What are your top health goals for the next 90 days? *

Why is achieving these goals important to you, both in your day-to-day life and in the bigger picture of who you want to become? *

What's the biggest obstacle that's been holding you back from reaching those goals so far? *

If that obstacle disappeared in the next 30–60 days, what would feel different in your life, body, or confidence? *

What kind of support do you most need right now? *

Accountability and consistency

A clear plan tailored to my body and lifestyle

Support around mindset or motivation

Expert guidance and feedback

A sustainable structure I can stick with

(Select up to 2)

What type of membership model best fits your wellness goals at this time? (copy) *

Individual ($129/mo Founding Members)

Couple ($199/mo Founding Members)

Family (2 adults + 2 kids) ($249/mo Founding Members)

Names & ages of all members

This is a cash-pay membership. Most members invest $300+ in functional lab testing, and supplement needs vary by person. While there’s no minimum contract, are you willing to commit at least 4–6 months to this process to see meaningful results? *

Yes – I’m ready and able to invest in myself

I’m ready to invest, and I’d need a flexible payment plan to make it work

No – I’m not in a place to invest in coaching right now

If you're accepted into this membership program, when would you want to get started? *

Right away

Within the next month

I’m not ready anytime soon

I understand this is a direct-pay membership (no insurance billing) and not emergency/urgent care. *

Yes – I am able to pay with cash, credit, or HSA/FSA

No – I prefer an insurance-based model of care

Is there anything else you’d like to share about your health journey or your desire to be part of this program? *

I consent to receive communications and understand I can opt-out at anytime.

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