AIW_Program_Application Form Embed

Name*

First Last

Preferred Email Address*

What is the URL of your personal Facebook profile or your Instagram Handle? Tell us which you use more, so we can add you as a friend and answer your questions in real time!

Facebook: Login to your account and view your profile. The address in the url bar is what you're looking for. (Exp. www.facebook.com/"user-name-here") Instagram: Your username is your handle (Exp. www.instagram.com/"user-name-here")

Cell Phone*

Input as ( # # # ) # # #-# # # #

Text Message Consent*

Terms of Use & Privacy Policy: Text messages are used for application updates and important program reminders. By checking the "I agree" below on this form, you agree to receive up to 5 auto-dialed marketing text messages per week delivered to the phone number provided at opt-in. Text HELP for info. Text STOP to cancel. Consent not required to purchase goods or services. Message and data rates may apply.

I agree

Biological Sex*

Female

Male

Date-of-Birth*

YYYY

Have you been officially diagnosed with autoimmune disease?*

Yes

What leads you to believe that your condition is autoimmune (symptoms, family history, Lab testing, etc.)?*

What have you tried to address your condition so far? How well has it worked?*

What are your long-term health goals and what do you hope to accomplish by enrolling in this program?*

Do you have a primary care physician or specialist who is managing your care?*

Yes

Are you willing and able to implement lifestyle changes and to take high-quality, professional-grade supplements in some form (liquid, capsules, etc.)?*

Yes

Maybe

Are you seeking help because you want to or because someone else wants you to? **

I want to

Someone else wants me to

If you're seeking help because someone else wants you to, who is it and what is your relation to this person?*

Write Name & Relation

On the scale of 1-10 (with 10 being most motivated), how motivated are you to make long-term changes to improve your health. Consider these areas: diet restrictions, drinking herbal teas, eliminating personal care products, exercising regularly and documenting your progress.*

Is there another decision-maker who would have to approve your investment in this wellness program? **

Yes

Other decision maker's name & relation to you?*

This person will be required to be involved in the conversations about your application.

Do you plan to go on any extended personal or business trips that will last more than a weekend over the next 3 months that may make it more difficult to attend group meetings or stick to a new lifestyle (dietary changes, supplements, sleeping schedule, environmental toxins, etc.)?*

Yes

On a scale of 1-10 (with 10 being the most committed), how committed are you to seeking a comprehensive approach (that doesn’t include adding more pharmaceuticals) for at least a 3-month period?*

What are your most annoying life hindering symptoms?*

What would you do if you could eliminate those symptoms? What would it mean for you?*

Why is it important for you to find a solution for your condition now instead of sometime in the near future?*

Is there anything else you think we should know about you (for example, details about symptoms or diagnoses, medications, current location, etc.)?

ACE Defying Autoimmune Wellness Program Application

AIW_Program_Application

ACE Defying Autoimmune Wellness
Program Application