Full Name *

Email *

Phone *

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Is your child currently struggling with ADHD and/or high-functioning autism symptoms that are affecting their focus, emotional regulation, academic performance, or social relationships? *

Yes, significantly

Somewhat

What is the BIGGEST challenge you're facing with your child right now? (Select all that apply) *

Frequent meltdowns or emotional outbursts

Inability to focus or complete tasks at school

Academic struggles despite being intelligent

Social difficulties or lack of friends

Constant calls from teachers or school administrators

Medication isn't working or has troubling side effects

Walking on eggshells at home to avoid triggering outbursts

Impact on siblings and overall family harmony

Other (Add Below)

Other (Enter N/A)

What kind of investment do you have available to help your child thrive? (Please be honest—this will affect the approach and strategy we recommend) *

I have $20k or more to invest in my child's transformation

I have $10k - $20k to invest in my child's transformation

I have less than $10k to invest in my child's transformation

I have less than $5k to invest in my child's transformation

I don't have any budget to invest in this at all

How confident are you that you are ready to work with Yana to transform your child's wellbeing? *

100% confident. That's why I'm booking this call. I'm eager to invest in my child's future and I can't wait for Yana to help my family. I'm ready to go!

90% confident. I just need to discuss a few quick details on the call and I'm ready to invest in my child. I'm ready to go.

50% confident. I'm not ready yet, and I won't enroll in Yana's program here on the first call. I need a chat, then likely more info, then likely more time to think too. I'm nowhere near ready to go yet.

0% confident. I'm just curious and exploring options. I have no intention of investing in a program right now.

Are you committed to making dietary and lifestyle changes for your child's wellbeing, even if it requires effort and consistency? *

Yes, absolutely. I'll do whatever it takes.

I'm willing to try, but I have concerns about implementation.

I'm not sure I can commit to significant changes.

If your spouse/partner is involved in childcare decisions, are they supportive of exploring a root-cause approach to your child's challenges? *

Yes, we're both on board

My partner is skeptical but willing to listen

My partner is not supportive

I'm the sole decision-maker for my child's care

Do you have a spouse/partner/co-parent that needs to be on the call and part of making a decision? *

Yes, we both need to be on the call and both be a part of making a decision.

No, we have discussed and I am able to make the decision on my own. They support me in the decision I make.

Not applicable

I confirm 100% that I can make the time I've selected and understand that if I don't show up or if I reschedule less than 12 hours before my chosen appointment time, I won't be able to book another call. *

Yes