Application to Work with Jarrod Cooper 1About you2Your health3Program First Name(Required)Surname(Required)Email Address(Required) Mobile Number(Required)Country and time zone(Required)Age Briefly describe your main health concerns and how long they have been present(Required)Which areas are currently affecting you? (Select all that apply)(Required) Chronic fatigue / burnout Digestive issues (bloating, reflux, IBS, constipation, diarrhoea) Autoimmune or inflammatory condition Hormonal or thyroid concerns Mood, anxiety, depression, or sleep issues Metabolic or weight resistance Long COVID, mystery illness or post-viral illness Other (please specify): Which areas are currently affecting you? (Other)(Required)Have you worked with other practitioners for this condition?(Required) Yes – multiple practitioners Yes – one or two practitioners No – this is my first time seeking this level of care Have you previously completed any functional or advanced testing? (Select all that apply)(Required) Comprehensive stool testing (GI-MAP or similar) Hormone testing (DUTCH or similar) Organic Acids Test (OAT) Extensive blood testing None of the above Which program are you applying for?(Required) Functional Medicine Case Review Program – 3 Months ($4,500 AUD) Comprehensive Functional Medicine Care – 6 Months ($7,500 AUD) Advanced Functional Medicine Care – 12 Months ($12,500 AUD) Not sure – seeking guidance on the best option Which statement best describes you right now?(Required) I want clarity and a clear plan for my health I am ready to commit to a structured functional medicine process I am exploring options and gathering information I am unsure but want professional guidance Is there anything that may limit your ability to commit to a structured care program if accepted?Why do you feel now is the right time to properly address your health?(Required)Please confirm the following:(Required) I understand that this is program-based care, not a single consultation, and that program fees range from $4,500–$12,500 AUD, excluding testing and supplements.
