Getting Started Form

Are you completing this application for yourself or someone else?

If you are completing this application for someone else, write your contact info here. Skip this section if you are the patient.

Full Name

Number

E-mail Address

Please provide information for the person requesting medical treatment at Deeper Healing.

First Name *

Last Name *

Date of Birth *

City *

State / Province *

Country

Phone *

Email *

On a scale from 1–10, how ready and committed are you to improve your health if the right solution is available?

1-2 Just exploring my options

3-4 Interested and want to learn more

5-6 Serious, but need a few months

6-8 Ready to take action in the next 30-60 days

9-10 Fully committed and want next available appt

What are the health challenges you are wanting to solve?

(Tell us your health goals — big or small)

How much are these health issues affecting your daily life?

MILD: I notice them, but they don’t interfere much

MODERATE: They interfere with some areas of my life (work, family, social)

SIGNIFICANT: They affect my emotions, confidence, and ability to function

SEVERE: I worry I won’t be able to live the life I want if this continues

What is your biggest motivation to solve your health issues now? Select all that apply to you:

To age well, keep mind sharp and prevent disease

To be present with my family, friends and/or kids

To perform better at work, school or career

To have energy and freedom for hobbies and travel

To feel like myself again emotionally and physically

Healing takes time and consistency. Our programs require active participation and making necessary lifestyle changes.

Are you able and willing to commit to this?

Yes, I'm ready to do whatever it takes to heal

Maybe, depending on what's involved

No, I need something less intensive right now

Describe how your life would be different 3-6 months from now with your health issues resolved:

Do you understand that Deeper Healing does NOT accept traditional health insurance or medicare?

Yes, I understand and I can pay out of pocket

No, I was hoping they took insurance

We do accept HSA, FSA, Care Credit and have financing options available. Some patients with Health Share Plans may qualify for reimbursement depending on their plan.

Since we do not accept insurance, how do you feel about investing in your health right now?

I’m ready and able to invest - my health is a top priority

I’m ready and want to learn about what payment plan and financing options are available

I'm still gathering information and want to speak to someone to learn more

I struggle with the idea of spending money on my health

Our new patient packages & programs typically start at $1,500 and vary depending on your needs.

Are you able to come to Deeper Healing Medical Wellness Center in Charleston, SC for in-person testing and care?

Yes

Maybe

I am unable to travel and would like to schedule a phone or zoom telehealth consult

(Note: Many of our programs begin with in-office assessment, but we do offer select remote telehealth services.)

Were you referred for our 2-week Medical Intensive Stay + Heal program?

Yes, and I want the next available appointment

No, but I'm interested in learning more

No, I do not need intensive medical treatments

The Stay + Heal Program involves traveling to Deeper Healing in Charleston, SC for specialized lab work, daily treatments, personalized monitoring, and accelerated healing protocols. The investment is typically $8000+ per week (plus travel and accommodations).

Are you the primary decision maker regarding your healthcare?

Yes – I am able to make my own health decisions

No – I rely on a family member or someone for support to make my health decisions

Is there a support person that you would like to be a part of your discovery call (name and number)?

Which way do you prefer to be contacted?

Phone call

Text