Full Name

Email *

Phone *

Social Media Handle

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Your Now vs. Your Future

1. On a scale of 1–10, how would you rate your current energy? *

2. What are the top 3 things you struggle with most in your body right now? (e.g., bloating, fatigue, puffiness, mood, stress, sleep) *

3. How do those struggles impact your daily life? *

4. Imagine it’s 6 weeks from now — what’s the biggest win you’d LOVE to see in your body or lifestyle? *

Your Motivation

5. Why did you say YES to the Reset right now instead of waiting? *

6. What’s at stake if nothing changes in the next 6 months? *

7. What excites you most about starting this journey? *

8. When you picture your “after” moment, what does that look like? (e.g., more confident, lighter, radiant, calm) *

Lifestyle & Logistics

9. Best days/times for sessions. *

10. Preferred communication style (WhatsApp, Voxxer, text, email) *

11. Is there anything you want me to know so I can best support you? *

Commitment

12. I understand spots are limited, and my enrollment is only confirmed once payment is completed.

YES

13. I’m ready to give myself fully to this Reset and show up each week.

YES