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The Autoimmune Revolution Application
READ BEFORE FILLING FORM!!!
You may not realize this at the moment, but filling out this form is the beginning of your final journey to getting your health back on track and into remission FAST.
We receive over 20 applications per week. Your time is very valuable, as is ours. We only speak with women who are serious about getting the life changing help they need.
Keep in mind, filling out this form is essentially a screening for one of the exclusive spots into the program. As we need to make sure based on your answers that we can help you and you're ready to get help.
Bri from The Autoimmune Revolution team will send you a text to acknowledge that we received your application and ask you to book a time for a phone call. Please do this the SAME day she contacts you.
The purpose for the call is to figure out what it is that you really want and to identify the things that have held you back from having that life you want.
Consider this a FREE breakthrough coaching call! We’re going to figure out where you have gaps right now in your healing journey and then we’re going to figure out a game plan to get your health transformed.
Thank you!
* Required
What is your first name?
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Your answer
What is your last name?
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Your answer
What is your age?
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Your answer
What is your health condition/diagnosis?
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Your answer
What is your occupation?
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Your answer
Are you a member of the PCOS Powerhouse, Hashimoto's Academy or Living Beyond Endo Facebook Group?
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Yes
No
How many years have you had your illness for?
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Your answer
Which email address shall we use?
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Your answer
What number do you want to be reached on? (if international, Skype or iPhone)
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Your answer
What caused you to be ready to work with The Autoimmune Revolution?
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Your answer
How much money have you spent in you search to get your health back to normal?
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Under $500
$500-$1000
$1000-$5000
$5000-$10,000
$10,000+
What do you feel like your biggest challenge is?
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Your answer
Describe the kind of health that would make you the happiest?
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Your answer
What is your urgency for solving this problem?
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Super urgent! I can't live like this if there's a real solution.
Not urgent at all. I'm comfortable where I am.
What is your #1 MOST important goal right now?
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Your answer
What has stopped you from achieving your goal?
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Your answer
How much is your health diagnosis affecting your relationships, social life, confidence, money, career, etc?
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Your answer
What have you tried to solve your challenge so far?
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Your answer
Are you ready and willing to commit to a final solution or do you want to keep exploring on your own?
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YES!
No.
What type of solution are you looking for?
I'm looking for more information and to do this on my own.
I'm doing okay, but I want more progress.
I'm not getting anywhere, I'm frustrated, and I want more results and personalized support.
Clear selection
If you are accepted, do you have the resources to invest in your health? If not, are you willing to be resourceful to make this happen? (We understand times are difficult right now, thus we are flexible so it becomes feasible for everyone)
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Yes, I have the resources.
I do not have the resources, but I am willing to become resourceful.
No, I do not have the resources and I am not willing to become resourceful in order to invest in myself and reclaim my life.
How did you hear about The Autoimmune Revolution?
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Your answer
Just out of curiosity, how long have you been following Justin (founder of the AIR) and reading/watching his content on social media?
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Your answer
Does anyone else have a say in whether or not you invest in this program? If so, who is the financial decision maker who will be joining us on this call?
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Your answer
I understand that this requires a commitment and investment on my part, BUT I also understand the cost of not being healthy.
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Yes.
No.
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