REWIRE LAB APPLICATION

Thank you for your interest in the REWIRE HEALTH LAB by Rewire Revival!

We are excited to get to know you through this application process. The questions are designed not only to help us get to know you but also to offer an opportunity for self-reflection as you consider how this program aligns with your personal health aspirations. Each application is thoughtfully reviewed. Admission to the program is not guaranteed, as we want to ensure the program and your goals are the right fit. Once we've reviewed your application, you can expect to hear from us within two to four business days. If you have any further questions, you'll have the option to email or schedule a follow-up call with our team. The application takes between 10 - 30 minutes. We're looking forward to learning about you!

First Name *

Last Name *

Phone *

Email *

In our live group sessions, what time is preferrable? *

HEALTH & WELLNESS GOALS

SERVICE PREFERENCES

Which part of the program are you most interested in? (Check all that apply): *

Neuro Drills for regulating my nervous system

Addressing health issues

Learning how functional medicine supports me

Managing emotions & heart wounds better in my body

Learning to trust myself

Getting my lab results & finally seeing a health path

Become equipped to be highly functional person

HEALTH HISTORY

Do you have any medical conditions or injuries we should be aware of? *

If yes, please specify:

Is there anything else you’d like us to know about you or your wellness journey? *

Which was of these statements resonate with you?

I'm ready to move beyond surface-level tools to create sustainable change

I want to feel more prepared, at peace, aligned, focused, and ready to go next level in my health

I think my autoimmune diseases, perimenopause, or digestion issues is keeping my body from having the life I desire

I wish I could trust my decisions more

The REWIRE LAB curriculum touches on subjects such as trauma, mental health, anxiety, and shame. Are you ready to explore these topics with your pracititioner?

Yes, I'm ready to commit

No, am hesitant

What impact would nervous system regulation and/or functional medicine have on your lifestyle? *

If you're accepted, what would make this health investment a YES for you? *

How did you hear about the Rewire Lab? *

By checking this box, I consent to receive non-marketing text messages from REWIRE REVIVAL.

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