R5 Reset Program Application

First Name

Last Name

Phone

Age

How did you hear about Nicky and the R4 Reset Program? Did someone refer you?

Which best describes you (choose all that apply)(required)

What best describes your physical condition right now?(required)

What is the #1 challenge/problem you are looking to solve in order to improve your health?(required)

Eating without guilt & restriction Lose the belly fat and feel strong Prioritize self and my health Find more energy without burning out All the above I'm not sure what is holding me back

Please provide as much detail as possible about the main obstacles/challenges that are preventing you from getting rid of fatigue, low energy and extra belly fat?

Are there any other big struggles or “roadblocks” that you face?

What types of things have you tried in the past to solve these problems? How did it go?

Are you under the care of a doctor for any medical conditions right now? Please describe. Any medications?

What are your TOP 2-3 things you would like help with?

Why are these things important to you?

What would reaching these goals allow you to do?

Why is now the right time for you to address these issues?

How serious are you about simplifying your health routine to eliminate bloating & belly fat and improve energy & focus? Choose a number to indicate your commitment level.
(1 = being not serious/just curious)
(10 = being very committed and serious about reaching my goal!)

Are you able to commit at least 2 hours a week to working on your health? *

Yes

Will you be able to honor your scheduled appointments with your coach? If something does come up and you need to reschedule, we ask you simply give us a timely heads up. Can you do that?

Yes

Can you commit to being coachable and follow our proven process? We will show you exactly what to do and how to do it and some of it will even be done for you. Will you be able to follow our guidance and show up with the best version of yourself?

Yes

If I am selected and decide to work with you, I’ll find a way to invest in myself and my future

I have the necessary means to invest in my health and future I have the ability to get the necessary means to invest in my health and future I have no financial means to invest in my health and future

R5 Reset Program Application

Please complete the application form below to apply for The R5 Reset Program with Integrated Health Practitioner, Nicky DiVicino. Thank you for your interest! I look forward to learning more about you.

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