SECTION 1 — PERSONAL & PROFESSIONAL DETAILS
First Name
*
Last Name
*
Phone
*
Email
*
Age
*
City & Country
*
What do you do for work? (Occupation + Industry)*
How long have you been in your current role/company?
*
Less than 1 year
1–3 years
3–7 years
7–12 years
12+ years
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How many hours per week do you typically work?
*
Under 30
30–40
40–50
50–60
60+
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What best describes your current income level?
*
Under $75k
$75k–$125k
$125k–$200k
$200k–$350k
$350k+
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SECTION 2 — HEALTH, STRESS & BURNOUT
On a scale of 1–10, how burnt out or stressed do you feel right now?
*
1
2
3
4
5
6
7
8
9
10
What symptoms of burnout, anxiety, stress or panic are you currently experiencing?
*
What symptoms of burnout, anxiety, stress or panic are you currently experiencing? (Tick multiple)
Physical exhaustion
Mental exhaustion
Emotional numbness & detachment
Brain fog & poor concentration
Impatience and irritability
Poor sleep
Withdrawal from people
Loss of joy
Excessive worry
Restlessness
Heart palpitations
Shallow breathing
Digestive issues
Muscle tension
Fear of something bad happening
Avoidance behaviours
How long have you been feeling this way?
*
Less than 3 months
3–6 months
6–12 months
1–3 years
3+ years
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What have you tried so far to improve your burnout, anxiety or panic attacks? What worked and what didn’t?
*
SECTION 3 — COMMITMENT & READINESS
On a scale of 1–10, how committed are you to making the lifestyle changes needed to recover from burnout, anxiety or panic disorder and rebuild your life?
1
2
3
4
5
6
7
8
9
10
SECTION 4 — TIME & ACCOUNTABILITY
Are you able to dedicate 2–5 hours per week to improving your health, routines and mindset?
*
YES
NO
MAYBE
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Application Submitted
Thanks for completing your application. Mark & his team will review your
answers and let you know if you're a fit for The Thrive Method.
