Application for Working with Dr. Rewire

Thank you for your interest in working with Dr. Rewire! Please take a moment to answer the following questions so we can better understand your goals and how we can help you achieve them.

First Name *

Last Name *

Email *

What is your current health and performance goal, and what are you hoping to achieve by working with Dr. Rewire? *

Please be specific—e.g., improve energy levels, break through mental blocks, achieve a specific milestone in your career or health.

Have you worked with a coach or participated in a personal development program before? If so, what was your experience like? *

What is your biggest obstacle or challenge right now when it comes to your health, mindset, or performance? *

We want to understand where you feel stuck or where you could use the most support.

Why do you believe now is the right time for you to make this change and commit to working with Dr. Rewire? *

What’s motivating you to take this step today?

Are you ready and willing to commit to 2 days with Dr. Rewire? *

Yes, I'm in!

Maybe, I'm nervous!

On the next page you'll get the opportunity to attend your first event with Dr. Rewire at a special rate!