Synthesis Health Group Application (Guest)

1

Are you applying as a licensed healthcare provider/student or for your own self healing?* This field is required.

I'm hear to learn to improve my own health.

I'm here to learn to improve my professional practice and provide the best care possible for others.

2

Honestly, which best describes your attitude towards healing?* This field is required.

I am open and ready for new health solutions, and I believe there is a way for me to get better.

I am jaded and burned out from trying and failing, but still optimistic there's hope.

I'm just here to learn more

3

How much are your symptoms interfering with your life?* This field is required.

My symptoms interfere significantly, but I still push through to have the fullest life possible

My symptoms interfere significantly and I've given up doing so many things that I used to enjoy

My symptoms are mild and rarely interfere with my life

4

What is Your Age?* This field is required.You must be 18 or over to join our group. If under 18, your parent/guardian may apply on your behalf.

18 - 21

22 - 29

30 - 39

40 - 49

50+

5

What's your name?* This field is required.

First Name

Last Name

6

If your application is successful, what is the best way to let you know?* This field is required.You can choose more than one method

Signal

Facebook Messenger

Email

7

What is the link to your Facebook profile?So we can make sure we have the right person when we let you know your application status via FB messenger (we will not contact you for any other reason) You can find your link by going to your own profile page and copying the URL from the address bar there.

8

What is your mobile phone number?* This field is required.This is very important so that we can recognize you in our SH group chat. We respect your privacy and do not call you, text you, or bother you in any capacity.

9

Your favorite Email Address?* This field is required.So we can let you know your application status via email (we will not contact you for any other reason) Make sure you check your junk/spam/promotions folders in the next 24-48 hours

example@example.com

10

What country/nation do you live in?* This field is required.

11

What do you do for a living?* This field is required.

Occupation

12

Where did you hear about Mel / Synthesis Health?* This field is required.If you were referred by a specific practitioner, please share their name. If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question

14

Please describe how you would like us to help you specifically?* This field is required.Be as detailed and specific as possible

15

Please list everything you've tried in the past to improve your health, and how much each cost* This field is required.Practitioners, Programs, Courses, Retreats, Supplements, Products, etc

16

What are some of your biggest challenges to healing right now?* This field is required.What's blocking you from getting better? If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question

17

Please share something you believe to be true about your health that almost everyone else disagrees with you on?* This field is required.Be as detailed and specific as possible If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question

18

If we were sitting down and talking a year from now, what would have needed to change for you to feel successful with your health?* This field is required.Be as detailed and specific as possible If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question

19

If we could wave a magic wand and give you only one wish, which would you choose?* This field is required.

I would wish to have my symptoms go away 100% for a year, and then return as they were

I would wish for my symptoms to reduce by 50% and stay that way for the rest of my life

20

Why did you choose that specific answer?* This field is required.Be as detailed as possible If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question

21

Are there any unique factors we should know about your case while considering your application?* This field is required.If you're having problems clicking "Next" and using a mobile device, write your answers and then gently swipe up and then click the next arrow for the next question

22

Do you agree to respect our Group Rules?(They're straightforward can be read within our new guest check-in area)

Yes!

23

By signing below I agree to follow the group rules, and to complete my check in process within 72 hours once I've arrived. My answers on this form are accurate, true and honest; this form is complete and ready to be submitted to Mel.

Clear