Application To Join Functional Health Upgrade Coaching ProgramΔApply Now to Join the Functional Health Upgrade Coaching ProgramHelp us understand your needs so we can guide you to better healthBasic InformationLet’s start with the essentials to get to know you better.Your Full NameEmail AddressPhone NumberInstagram or Facebook HandleLocation– Select Country –AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweAge– Select Age Range –20-2930-3940-4950-5960+Gender Male Female Prefer Not To SayHealth and LifestyleTell us about your health priorities and the obstacles you’re facingWhat are your current health goals?How would you describe your current health status?– Select –ExcellentGoodFairPoorAre you currently under the care of a healthcare provider or coach?– Select –YesNoDo you have any chronic health conditions or medical history we should know about?Current Habits and RoutineYour daily routines and past efforts shape your health journeyOn average, how many hours of sleep do you get per night?– Select –Less than 55-67-8More than 8How often do you exercise?– Select –Daily3-5 times a week1-2 times a weekRarely/NeverDescribe your current diet– Select –BalancedHigh ProteinLow CarbVegetarian/VeganOtherHow would you rate your stress levels?– Select –LowModerateHighVery HighInvestment and CommitmentWe’re looking for clients ready to invest in their health and commit to lasting changeAre you willing to invest in your health and well-being? Yes NoHave you invested in health coaching or wellness programs before? Yes NoWhat is your budget for health and wellness coaching?– Select –$1,000-$2,000$2,000-$5,000$5,000+I’m unsureHow committed are you to making significant changes to your lifestyle?– Select –Extremely CommittedSomewhat CommittedNot SureNot CommittedTime AvailabilityLet’s determine if your schedule aligns with the commitment needed for this programHow many hours per week can you dedicate to working on your health?– Select –Less than 22-44-66+Are you ready to start the program within the next 30 days? Yes NoMotivation and ReadinessUnderstanding your motivation helps us tailor the program to achieve your goalsWhy do you want to join the Functional Health Upgrade Coaching Program?What would be the biggest impact of achieving your health goals?What has been your biggest obstacle in achieving your health goals so far?Referral and BackgroundYour connection to us and any additional information will help us make the best decisionHow did you hear about us?– Select –ReferralSocial MediaWebsiteOtherIs there anything else you would like us to know before we consider your application?Submit