Full Name
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Email
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Phone
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Age Range
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Age Range
55+
45–54
40–44
35–39
Under 35
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Are you ready for a long-term strategic rebuild — not another reset?
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Yes
No
Not Sure
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What are you here to change right now? (Choose all that apply)
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Weight resistance / stalled body composition
Stubborn belly weight / puffiness / inflammation
Gut issues (bloat, constipation, reflux, irregular digestion)
Hormone shifts (peri/menopause symptoms)
Sleep + fatigue / wired but tired
Energy crashes / cravings / blood sugar swings
Brain fog / mood shifts / anxiety
I want full-body optimization
What have you already tried that “should have worked,” but didn’t? (Short answer)
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What would a measurable win look like 6 months from now? (Short answer)
*
Which of these are true for you right now? (Check all that apply)
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My body doesn’t respond like it used to
I train and eat clean but my body composition is stuck
Sleep doesn’t restore me
I feel puffy/inflamed (face, belly, joints)
Digestion is unpredictable
Cravings feel louder than my logic
I rely on caffeine to function
I feel wired but tired / under-recovered
Labs are “normal” but I don’t feel normal
How ready are you to start in the next 30 days if we’re a fit?
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Ready now
2–4 weeks
1–3 months
Just exploring
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This is a 6-month private mentorship and a premium investment. If we both agree it’s a fit, are you prepared to invest?
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Yes
No
Possibly, I need details
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Are you the decision maker for this investment?
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Yes
No / I need to consult someone
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