Application for Dr. Ritamarie Private Coaching

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Email *

First Name *

Last Name *

Best Phone Number *

What's your main objective for working with Dr. Ritamarie? Please provide details about any health challenges and goals you'd like to achieve. *

On a scale of 1 - 10, how committed are you to this outcome? *

Minimally committed

100% committed

Which of these areas of your life are impacted by your current health situation? *

Career

Relationships

Social life

Other:

Required

What is the cost to you, in terms of finances, relationships and fun, of not solving your current health challenges? *

Are there any foods or activities you are unwilling to include in your life, no matter the positive impact they would have on your health? If so, please describe. *

Are there any foods or activities that you are unwilling to give up no matter what the cost in terms of your health? If so, please list. *

If selected, how much time are you willing to invest to get your health challenges resolved and allow you to achieve vitality? *

An hour a week or less

Several hours a week

Several hours a day

Whatever it takes

What's the most you are you willing to invest to resolve your health challenges and achieve unstoppable health and vitality? *

$10,000 or less

$30,000 or less

$50,000 or less

Whatever it takes

Is there anything else you'd like to share, to explain why we should choose you as one of the participants in this program? *

Thanks for completing this application. We'll get back to you within a few days to set up an appointment to discuss if we feel you are a good fit.

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