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Coaching and Consulting Application

First Name

*

Email address

*

What's your age and sex? (helps me diagnosis common conditions)

*

Untitled checkboxes field

Male

*

Female

Prefer not to answer

What do you do for work?

*

I'm currently having...

*

I'm currently having...

Shoulder pain

Neck/upper back pain

Knee pain

Low back/hip pain

Foot/ankle, lower leg pain

Other

I've had this pain for

*

I've had this pain for

Less than 3 months

6+ months

1+ year(s)

What's the biggest obstacle to improving your pain?

*

If your pain was gone, what specific events or goals would you like to accomplish?

*

What do you think would happen if you did nothing for the next 6 months?

*

Are you ready to commit to a personalized plan to address your issues?

*

Are you ready to commit to a personalized plan to address your issues?

Yes

No

What investment option works best for you?

*

What investment option works best for you?

Paid in full ($1500 - save $900)

Monthly recurring ($600 month for 3 months)

Is there anything else you feel is important to tell me before we start?

*

Are you over the age of 18? If not, please provide your guardian's email below. Please note we will not have any virtual calls with you without a legal adult present.

*

Are you over the age of 18? If not, please provide your guardian's email below. Please note we will not have any virtual calls with you without a legal adult present.

Yes

No

Coaching and Consulting Application

First Name

Email address

What's your age and sex? (helps me diagnosis common conditions)

What do you do for work?

I'm currently having...

I've had this pain for

What's the biggest obstacle to improving your pain?

If your pain was gone, what specific events or goals would you like to accomplish?

What do you think would happen if you did nothing for the next 6 months?

Are you ready to commit to a personalized plan to address your issues?

What investment option works best for you?

Is there anything else you feel is important to tell me before we start?

Are you over the age of 18? If not, please provide your guardian's email below. Please note we will not have any virtual calls with you without a legal adult present.

Guardian email