MV Solutions + Support Application (YTP)

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Which of these best describes your goals here?* This field is required.

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

I'm a healthcare professional interested in mentorship and advanced clinical training

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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 cautiously optimistic there's hope

I'm just here to learn more

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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

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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

30-40

40-50

50+

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Your Name* This field is required.

First Name

Last Name

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What is your phone number?* This field is required.So we can recognize and correctly add you in our chat group. We will not contact you for any other reason. If you're outside the US you must include your country code

example: 555 - 698- 5575, or +61 555 555 555, etc

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Your Favorite Email Address* This field is required.So we can let you know your application status via email (we will not add you to any mailing lists or contact you for any other reason)

example: yourname@example.com

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

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What do you do for a living?

Occupation

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How did you discover Jeremy / Modern Vitality?* This field is required.Was there a specific video or post that resonated with you and made you want to apply? What was the title or topic?

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Was there a specific video or post that resonated with you and made you want to apply? What was the title or topic?Please be specific

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What are the top 1-3 things you'd like help with regarding your health?* This field is required.What are your most difficult symptoms? Do you have any diagnosis? What are your health goals? Please be as detailed and specific as possible (You're over halfway through the application now)

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

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What are some of your biggest challenges to healing right now?* This field is required.What's blocking you from getting better? (only 3 questions left)

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Please share something you believe to be true about your current health situation that may be controversial or that others don't necessarily understandBe as detailed and specific as possible

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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?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

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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

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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

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Lastly, 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

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