Name *

First Name

Last Name

Phone *

Country

(###)

###

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How many hours of sleep do you typically get per night? *

Less than 5 hours

5–6 hours

7–8 hours

9+ hours

How often do you engage in physical movement (exercise, yoga, walking)? *

Daily

A few times a week

Rarely

Not at all

How would you describe your overall mental health right now? *

Excellent

Good

Average

Struggling

Do you practice mindfulness, meditation, or breathwork? *

Yes, regularly

Occasionally

Not yet, but I’m interested

No

What type of support do you feel you need most? *

Accountability and Motivation

Stress and Emotional Management

Mindfulness and Mental Clarity

Physical Wellness and Energy

All of the above

How do you prefer to receive guidance? *

Direct and action-based

Compassionate and supportive

A balanced mix of both

Are you open to incorporating holistic practices (breathwork, meditation, energy healing) into your program? *

Yes

No