This is not a form. It is a conversation — the one I wish every physician had with you before you walked through their door. Your answers will shape everything about our evening together and the program I am designing for you. Please be honest. There are no wrong answers here.

◆ About 10 Minutes ◆ Completely Confidential ◆ Read Personally by Dr. Verrico

First Name *

Last Name *

Email *

Phone *

The Single Biggest Thing

QUESTION 01 | SINGLE BIGGEST STRUGGLE

Right now, what is the single biggest challenge you are facing with your health — the one thing you most wish someone could help you solve? Don't filter yourself. Write exactly what comes to mind first. One sentence or ten — whatever is true. *

Who You Are & Who You Want to Be

QUESTION 10 | ASPIRATION — OPEN

If we could fast-forward 12 months and you were thriving — what does that actually look like for you? Be specific. What are you doing? How do you feel? What has changed at work, at home, in your relationships, in how you see yourself? *

QUESTION 11 | ASPIRATION — PRIORITY RANKING

Rank these outcomes from most to least important to you personally. Your #1 becomes the north star of your program design.

Energy & vitality — feeling fully alive again *

Least ImportantMost Important

Mental clarity — sharp, focused, confident *

Least ImportantMost Important

Body composition — feeling strong and comfortable in my body *

Least ImportantMost Important

Intimacy & sexuality — a vibrant, connected relationship *

Least ImportantMost Important

Cardiovascular & metabolic health — protecting my future *

Least ImportantMost Important

Identity & confidence — feeling like myself again *

Least ImportantMost Important

Community — women who truly understand what I'm going through *

Least ImportantMost Important

QUESTION 12 | ASPIRATION — THE COST OF INACTION

If nothing changes in the next 12 months — if you continue exactly as you are — what does that cost you? This is a hard question. But the honest answer is important for both of us. *

What Might Hold You Back

QUESTION 18 | THE PIVOT — HESITATIONS

What might make you hesitate to commit to a program like this? Select all that honestly apply. Your candor helps me design something you can actually say yes to. *

The investment — I need to feel certain before I spend at this level

Time — I don't know if I can commit consistently

Skepticism — I've invested in programs before and been disappointed

Privacy — I'm not comfortable sharing personal health details in a group

My partner — I need them on board before I commit

Uncertainty about hormones — I've heard conflicting things

I don't know enough yet to decide

Honestly — nothing. I am ready.

QUESTION 19 | THE PIVOT — THE REAL OBJECTION

If you could say one thing to me — completely honestly — that you might not say in the room, what would it be? This is your space. Say whatever is true. I will read it and I will honor it. *

Anything Else

QUESTION 20 | CLOSING OPEN

Is there anything else you want me to know before we meet — anything this survey didn't ask, anything you've been holding, anything at all? There is no wrong answer here. This is simply your space.

Your answers go directly and only to Dr. Verrico. They are held in complete confidence and read personally before our evening together

◆ About 10 Minutes ◆ Completely Confidential ◆ Read Personally by Dr. Verrico

The Single Biggest Thing

Understanding Where You Are

Your Symptom Picture

Who You Are & Who You Want to Be

How You Want to Work Together

What Might Hold You Back

Anything Else