Application for MBR Program- from podcast - Down to the Root Healing

Name: *
Email: *
Home Phone: *
Time Zone:

 TELL ME ABOUT YOURSELF


What time zone are you in?

{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}



How did you hear about the Mind Body Rewire Program?

{"type":"checkbox","name":"foundMe","width":50,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Facebook \nWeb Search\nPodcast\nA friend/person\nYouTube\nInstagram\nNewsletter\nOther"}



If a person referred you, please type their name below
{"type":"text","name":"__generic2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}



Do you work at this time?

{"type":"checkbox","name":"__generic3","width":33,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Full time\nPart time\nUnable at this time"}



Your Age

{"type":"text","name":"age","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


What are your biggest struggles when trying to heal your symptoms? 

{"type":"textarea","name":"struggles","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



What symptoms/diagnosis are you seeking help for?

{"type":"textarea","name":"symptoms","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



How long have you had these symptoms?

{"type":"text","name":"__generic7","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}



What kind of approaches have you tried to resolve these symptoms?

{"type":"textarea","name":"triedbefore","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



How does having these symptoms and not finding the solution make you feel?

{"type":"textarea","name":"feelings","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



If you could wave a magic wand when it comes to your health, what would your #1 desired outcome be in the next 6 months?

{"type":"text","name":"desiredoutcome","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}



What do YOU believe is the root cause to your symptoms?

{"type":"textarea","name":"rootcause","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



Have you ever worked with a coach or mentor before?

{"type":"text","name":"coachbefore","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}



What percent do you believe you are responsible for your healing?

{"type":"text","name":"__generic13","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}



On a scale of 0-10, how willing are you to be uncomfortable for the sake of your healing? 

  • 10 being that you know shifting old patterns can be uncomfortable but understand that its necessary to heal and are willing to do it. 
  • 1 meaning you don't want to be uncomfortable and you're not willing to make any changes to create the result that you want. 
{"type":"text","name":"__generic14","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}



Are you willing to put your healing and the work that is required for your healing as a priority in your life? This means you will need to spend 30-90 minutes a day on your healing. 

{"type":"checkbox","name":"__generic15","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}



Are you open to the idea that physical ailments have an emotional connection?

{"type":"checkbox","name":"__generic16","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}



What would be the length of time that you are willing to invest in your healing?

{"type":"checkbox","name":"__generic17","width":50,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"1 month\n3 months\n6 months\nWhatever it takes"}




What kind of solution are you looking for right now?

{"type":"checkbox","name":"__generic4","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"DIY Solution (money is tight & I'd rather learn and do it myself\nDone WITH me solution (do it myself with the guidance of a coach)"}



The MBR Program includes a variety of tools to assist with healing including, meditation, yoga, and hypnosis. Are you ok with using these?

{"type":"checkbox","name":"__generic5","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}



What do YOU think is the biggest block getting in the way of your healing?

{"type":"textarea","name":"biggestblock","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



What are the biggest reasons you're drawn to working with a coach versus healing on your own?

{"type":"textarea","name":"drawntocoaching","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



Are you on any medications? If yes, which ones?

{"type":"textarea","name":"medications","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



Are you open to healing your symptoms without detoxing, diet restrictions or pills?

{"type":"checkbox","name":"__generic21","width":33,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo \nMaybe"}



Have you listened to Jenny's Podcast (Simplify Your Healing Podcast) and have a good idea of the type of work that Jenny and her team does?

{"type":"checkbox","name":"listenedtopodcast","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\nNo"}


 

The MBR Program is a minimal investment of $1500. Does this fit within your budget or your ability to find the funds?

{"type":"checkbox","name":"__generic6","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}



May we inform you by text if you've been accepted?

If your application is accepted, we will send you the time-sensitive reply link via email. By checking this box, you also give us permission to text you and let you know to keep an eye out for that email. We are only using this for internal purposes only. 
{"type":"checkbox","name":"__generic8","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}