Independence by Design — Application

This is not a medical form.

It’s a short reflection so I can understand what independence means to you — and whether this programme is the right fit.

There are no right answers.

Take your time.

First Name *

Last Name *

Email *

Briefly describe your current work/life stage. *

How would you describe your current health trajectory in your own words? *

What does “independence” actually mean to you? *

If nothing changed over the next 10 years, what concerns you most?

What would feel like a warning sign that things are moving in the wrong direction?

What are you already doing consistently to protect your future health? *

Where do you feel strongest right now? *

Where do you feel most vulnerable?

What tends to disrupt your consistency? *

In 12 months, what would tell you this year had been worthwhile? *

In 5 years, what would you like to still be capable of without hesitation? *

What are you not willing to let happen? *

Why are you considering this now rather than 2 years ago? *

What kind of support works best for you? *

How much time per week feels realistic to invest in protecting your independence? *

Independence by Design is £4,800 per year.

If we agree it’s the right fit, how do you feel about that level of investment? *

Comfortable if it clearly protects my trajectory

I would want to understand the structure in detail

I would need to think carefully about the investment

It’s probably beyond what I’d invest right now

If this programme genuinely worked, what would that £4,800 represent to you? *

Any significant medical conditions, injuries, or current clinical care I should be aware of? *

Finish this sentence: *

Anything else you feel is important?

I read every application personally.

If it looks like a strong fit, I’ll respond with next steps.

If not, I’ll tell you clearly — and suggest something more appropriate.

Independence by Design is educational and supportive. It does not provide medical diagnosis or treatment.