Is this your first time applying for our help? *

Yes. This is my first time applying.

No. I've applied before and wasn't accepted.

No. I've already been through a program but need more help.

First Name *

Last Name *

Phone *

Please provide a mobile phone number in case we need to reach out to you for clarification about your application.

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Email *

What is your marital status? *

I am married.

I have a partner.

I am single.

Are you experiencing chronic pain, inflammation, hormone imbalance, and/or gut issues? *

Yes

I'm not sure

What is your #1 challenge with getting healthier? *

What have you tried or invested in that did not work? *

How are your health issues impacting your life (please be specific)? *

Why not just keep doing what you are doing to solve your health issues? *

How confident are you in your current health plan? *

Very confident ... I don't really need help. I'm just curious.

Somewhat ... I need help figuring out what's missing.

Not at all. I need help where to start.

How much would you be willing to invest in a solution that works for you? Please be as accurate as possible here.</p> *

Don't have the finances now, but maybe in the future.

$200 to $1K - As much as a nice TV or furniture

$1K to $3K - As much as a nice vacation

$3K to $5K - As much as a bathroom upgrade

I'll invest what I need to as long as it works for me.

Your response doesn't change our pricing... but it helps us understand your budget, program options within your budget, and importance.

As we review your application, could you please tell us why you think you'd be a good fit for our help? *

How did you hear about Naples Vitality? *

If referred by your physician, specific health practitioner/resource, or one of our practice members, please let us know their name.

If your application is approved and we both determine our help on your journey to get healthy is a mutual fit... will you be friendly and coachable? *

Yes. Absolutely.

No.

Who do you have to support you through your health journey? *

I have a spouse to support me.

I have a partner to support me.

I have a child to support me.

I have a caregiver to support me.

I have a friend to support me.

I would be doing this on my own.