Private Care Access Request

This application is not a test. It is a signal.

This where we begin to understand what your body and your life have been asking for.

Take your time. Your answers matter.

Please answer honestly and intuitively. Your responses help determine whether private care is the right next step - for both of us.

What do you prefer to be addressed by?

How did you find us?

Website

Referral

Social Media

Other

How would you describe yourself at your best?

What drew you specifically to this approach at Ai Vida Health?

What's your current state?

Mostly well, something feels off

Functional but not regulated

Tired of managing alone

Ready for deeper support

What does your life currently look like on the surface? (career, lifestyle, responsibilities)

How willing are you to engage?

I give my full attention once I commit

I do well with guidance and accountability

I’ve struggled with consistency but want support

I prefer flexibility and minimal structure

This level of care requires structure and consistent engagement. At this time, this may not be the right fit.

Primary Focus Areas (Select up to 3)

Hormone Balance & Cycle Regulation

Energy, Fatigue & Burnout Recovery

Gut Health & Digestive Repair

Skin Clarity & Inflammation Support

Sleep Quality & Nervous System Reset

Anxiety, Overwhelm & Emotional Regulation

Stress Resilience & Mental Clarity

Purpose, Direction & Life Transition Support

Cognitive Performance

Peak Performance & High Achievement Capacity

How long has this been affecting you?

What have you tried in the past to support your health or personal growth?

What frustrated you most about those experiences?

How ready are you to invest in yourself?

Comfortable investing in private care

Would need to consider carefully

Not sure yet

The cost of inaction. If nothing changes over the next 6–12 months, what would concern you most?

If this were fully resolved, how would your body feel on a daily basis? (energy, confidence, presence...)

If this were fully resolved, what would become possible for you that isn't fully available right now?

On a scale of 1-10, how ready are youth shift this now?

What not a lower number?

How do you prefer to be guided when working with an expert? (Select up to two)

Thoughtful accountability

Clear structure and direction

Collaborative refinement over time

Being challenged when appropriate

When you commit to something meaningful, what best describes how you follow through?

I stay consistent once I commit

I do best with structure and accountability

I engage deeply when aligned

Consistency has been a challenge

What's your typical stress response?

Push through

Shut down

Swing between both

Not sure

Describe your follow-thru patterns and consistency with daily habits

Are you willing to invest in a high level of personalized care

Yes

Private concierge care begins at $3,000/month with a minimum commitment. How does this land for you?

Aligned and workable

Open to discussing details

Not aligned at this time

If accepted, when would you be ready to begin?

Immediately

Within 2 weeks

Within 30 days

Gathering information/Exploring

Leadership Response

I appreciate clear leadership

I do well with structure once trust is built

I prefer to decide moment by moment

I don’t like being told what to do

At this time, this may not be the right fit.

Why does this feel like the right time for you to apply for private concierge care?

What would make this a nourishing and successful partnership for you?

Is there anything relevant you’d like me to know as I review your application?

Thank you for your presence and precision..

If alignment is confirmed, you will be invited to a private consultation where next steps are clarified calmly and directly.

If not, you will still leave with insight.

Either way, this interaction is complete.