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Application

Please click below to answer a few questions about your health. This will help us understand you better and provide the best support possible. We're excited to connect with you soon!

Click the button below to start.

Start

Question 1 of 28

Is this your first time applying for our assistance?

A

Yes

B

No. I applied before and was denied.

C

No. I have been through your program and require more help.

Question 2 of 28

Full Name

Question 3 of 28

Phone Number

Question 4 of 28

State

Question 5 of 28

Country

Question 6 of 28

Email?

Question 7 of 28

Marital Status

A

Single

B

Domestic Partnership

C

Married

Question 8 of 28

By clicking "yes" below, I agree to terms of services found via this link -> https://brandon-marsh.mykajabi.com/terms-of-service

A

Yes

Question 9 of 28

How much confidence do you have in your current health plan?

A

Very Confident

B

Somewhat

C

Not at all

Question 10 of 28

In which areas do you need the most help?

Question 11 of 28

How much are you willing to invest in a solution to heal?

A

I do not have the finances now, but perhaps in the future.

B

$200 to $1k - Same as a piece of furniture

C

$1k to 3k - Same as a vacation

D

3k to 5k - Same as a bathroom upgrade

Question 12 of 28

What have you already tried that has not worked?

Question 13 of 28

How are your health issues specifically affecting your daily life?

Question 14 of 28

Why not just keep doing what you're already doing to fix your health issues?

Question 15 of 28

How familiar are you with hormonal imbalances?

A

Expert

B

I've heard about it

C

Beginner

Question 16 of 28

What health issues are you currently experiencing?

Question 17 of 28

In the past 3 months, have you experienced any of these symptoms?

(Select all that apply)
A

White tongue coating

B

Intense Sugar Cravings

C

Heart Burn

D

Upset Stomach

E

Constipation

F

Diarrhea

G

Gas or Bloating

H

Excess Belly Fat

I

Hemorrhoids

J

None

Question 18 of 28

In the past 3 months, have you experienced any of these symptoms?

(Select all that apply)
A

Nervousness

B

Mood Swings

C

Hanger (anger only relieved by eating)

D

Difficulty Concentrating

E

Memory Issues

F

Skin Rashes

G

Acne

H

Intense Thirst

I

Intense Hunger

Question 19 of 28

Do you take any of these medications?

A

Birth Control

B

I did take birth control, but I no longer do.

C

Antacids

D

Antibiotics w/ in the past 5 years

Question 20 of 28

How often do you feel stressed?

A

Never

B

Rarely

C

Pretty Often

D

Almost Always

Question 21 of 28

How would you describe your sleep?

A

Sleep through the night and feel well rested

B

Sleep through the night, but do not feel well rested

C

Have trouble falling asleep

D

Wake up throughout the night

E

Cannot sleep through the night

Question 22 of 28

Do you struggle with:

(Select all that apply)
A

Nail Biting

B

Smoking

C

Stress Eating

D

Hypertension

E

High Cholesterol

F

Diabetes

G

Prediabetes

H

Easily Injured

Question 23 of 28

On average, how many cups of coffee do you have per week?

A

1-2

B

5

C

10

D

15

E

20 or more

F

None

Question 24 of 28

On average, how many alcoholic beverages do you have per week?

A

1-2

B

3-6

C

7-10

D

15 or more

E

None

Question 25 of 28

What is your top barrier to getting healthier?

Question 26 of 28

If you were to overcome your health issues, what would your life look like?

Question 27 of 28

If we are a good fit, will you be open and receptive to coaching?

A

Yes

B

No

Question 28 of 28

Please tell us why you think you're a good fit for our program?

Confirm and Submit