SECTION 1: ABOUT YOU

First Name *

Last Name *

Phone *

Email *

Age *

State *

SECTION 2: YOUR LISAMARIENP CONNECTION

Are you currently part of the LisamarieNP community? *

I’m a current or previous 1:1 client

I’m a current CRS client

I’m a CRS graduate

I’m a peptide client

I’m a bHRT / hormone client

I’m a Skool community member

I’ve completed another LisamarieNP program

I follow LisamarieNP but haven’t worked with you yet

I’m completely new to LisamarieNP

Select all that apply.

If you’ve worked with us before, what program or service have you participated in?

SECTION 3: WHAT’S GOING ON?

What are the top 3 health concerns you would most like help understanding or improving? *

How are these concerns affecting your everyday life? *

What have you already tried? *

This may include conventional care, functional medicine, diets, supplements, medications, hormone support, peptides, weight-loss programs, testing, coaching, or other approaches.

What do you feel has been missing from the help you’ve received so far? *

Are you currently under the care of a medical provider for any health condition? *

Yes

No

Are you currently taking prescription medications? *

Yes

No

Do you have recent laboratory testing available? *

Yes — within the last 3 months

Yes — within the last 6 months

Yes — within the last year

No / not recently

SECTION 5: WHERE ARE YOU NOW?

Which statement sounds MOST like you right now? *

I have a lot of information, but I don’t know what actually applies to me.

I’ve tried a lot of things and still don’t understand why I feel this way.

I’ve made progress, but I feel like I’ve hit a wall.

I’m mostly looking for someone to tell me which supplements to take.

I’m ready to understand the bigger picture and work on the foundations of my health.

How ready are you to make changes if we identify areas that need attention? *

1 = I’m mostly gathering information; 10 = I’m ready to actively work on this

What would need to change over the next 6–12 months for you to say, “This was absolutely worth it”? *

SECTION 6: WHY 1:1?

Why are you interested in working privately with Lisamarie rather than choosing a DIY, membership, or group program? *

Why does addressing your health feel important to you now? *

What kind of support helps you succeed? *

I like clear direction and a plan.

I want to understand the “why” behind what I’m doing.

Accountability is important to me.

I want personalized feedback as we learn more about my body.

I need help sorting through conflicting health information.

I do best with ongoing support rather than trying to figure everything out myself.

All of the above.

Select all that apply.

SECTION 7: READINESS & INVESTMENT

Private 1:1 coaching is my highest level of personalized support and involves a significant commitment of both time and resources.

If we determine that private 1:1 coaching is the right fit, are you prepared to invest in your health at this level? *

Yes — I’m prepared to invest if it’s the right fit.

Possibly — I’d need to understand the program and investment first.

I would need a payment option.

No — I’m primarily looking for lower-cost support right now.

If private 1:1 coaching isn’t the best fit right now, would you like us to recommend another way to work with Lisamarie? *

Yes

No

SECTION 8: ONE LAST QUESTION

Is there anything else you think Lisamarie should know when reviewing your application? *

ACKNOWLEDGMENTS

Lisamarie’s work is educational and coaching-based. It is not a substitute for medical care, diagnosis, or treatment. You should maintain an appropriate relationship with your licensed medical providers for medical evaluation, diagnosis, treatment, and prescribing.

I understand that LisamarieNP’s services are educational/coaching in nature and that submitting this application does not establish a medical provider-patient relationship.

I understand that joining the waitlist does not guarantee an opening or acceptance into private 1:1 coaching.

Not sure where to begin?

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Email us: [email protected]

Call us: 330-331-6627

Currently accepting patients in PA, OH, KY, and FL.

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