First Name
*
Last Name
*
Phone
*
Email
*
How would you rate the quality of your sleep currently? (1 = Poor; 10 = Excellent)
*
1
2
3
4
5
6
7
8
9
10
How many hours do you sleep on average per night (time spent asleep NOT time spent in bed)?
*
< 5
5-6
6-7
7-8
8+
Do you go to bed at a consistent time every night?
*
Always
Sometimes
Rarely
Never
How would you rate the level of stress in your life right now? (1 = No Stress; 10 = Chronic stress)
*
1
2
3
4
5
6
7
8
9
10
Do you ever feel that you’ve been affected by feelings of edginess, anxiety, or nerves?
*
Yes
No
Unsure
Have you ever experienced a week or longer of lower-than-usual interest in activities that you usually enjoy? Examples might include work, exercise, or hobbies.
*
Yes
No
Unsure
What is the source of your stress right now? (Pick all that apply)
*
Financial
Work
Health
Relationships
Family
Other
Why is that stressful?
*
I don't know how to deal with it
It's too overwhelming to deal with it
Both
Other
How long have you been feeling stressed out and overwhelmed?
*
1 - 4 Weeks
1 - 6 Months
6 - 12 Months
Over a year
What are your goals when it comes to your health over the next few weeks? (Pick all that apply)
*
Stress Relief/Management
Mental Clarity
Pain Relief
Improved Sleep
Other
What do you think is your #1 challenge when it comes to achieving those goals?
*
How committed are you to solving your stress problem? (1 = Not at all. 10 = Fully Committed)
*
1
2
3
4
5
6
7
8
9
10
"If someone advised me to spend $400-$1000 on my health & wellness, I would..."
*
Know it's an important part of managing my stress levels, and would do it with the the right accountability and system to follow
Would be a little intimidated, yet with a proven system I would do it because I do want to invest in my health
Avoid it, as I am looking for cheaper ways to manage my stress
Are you ready to book a 30 min call within the next 72 hours to see if you're a good fit for our program? Please note, If you are more than 5 minutes late, the call will be cancelled and you will NOT be able to reschedule another
Yes
No