The Autoimmune Revolution Application

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.

**Once you have completed the application and submitted your answers you will be directed to another page with a link to book a call with Justin. Please book the call immediately after completing this application.

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!
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What is your first name? *
What is your last name? *
What is your age? *
W​hat is your health condition/diagnosis? *
What is your occupation? *
Are you a member of the PCOS Powerhouse, Hashimoto's Academy or Living Beyond Endo Facebook Group? *
H​ow many years have you had your illness for? *
Which email address shall we use? *
What number do you want to be reached on? (if international, WhatsApp or Skype) *
What caused you to be ready to work with The Autoimmune Revolution? *
How much money have you spent in your search to get your health back to normal? *
What do you feel like your biggest challenge is? *
Describe the kind of health that would make you the happiest? *
What does the ideal version of your health in the next 6 months look like? *
What is your urgency for solving this problem? *
What are your top 1-3 MOST important goals right now? *
Why is it important for you to accomplish these goals in the next 6 months? *
What do you think has stopped you from achieving the results that you want? *
In what ways is your illness affecting your marriage, relationships, social life, confidence, money, career, etc? *
What have you tried to solve your challenges so far? *
Are you ready and willing to commit to a final solution or do you want to keep exploring on your own? *
What type of solution are you looking for? *
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? *
How did you hear about The Autoimmune Revolution? *
Just out of curiosity, how long have you been following Justin (founder of the AIR) and reading/watching his content on social media? *
If we determine we can help you and that you are an excellent fit for one of our programs, does anyone else have a say in whether or not you invest in yourself? *
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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