// THE INTAKE QUESTIONNAIRE

Apply for Coaching

Every field below helps us assess whether this program is the right fit for your weight-loss and baseline-dopamine goals. Please answer honestly — your responses are reviewed personally before any offer is made.

Personal Info

First Name (required)

Last Name (required)

Email (required)

Application

What is the goal you want to work on with Dr. Zaldívar's coaching? (required)

Why do you want to raise your baseline dopamine right now? (required)

On a scale of 1–10, how ready are you to change your daily habits for at least 90 days? (required)

When something in your life isn't working, what do you typically do?

Have you worked with a coach before? What happened? (required)

Are you currently in therapy or being treated for severe depression, bipolar disorder, or active substance dependency? (required)

How do you typically respond to stress?

On average, how many major life crises have you experienced in the last 6 months? (required)

Are you currently in a stable living and financial situation?

If you commit, are you able to complete the full coaching term regardless of temporary emotional fluctuations?

On a scale from 1 to 10, how open are you to strength training and structured physical programming? (required)

When presented with scientific evidence that challenges your current beliefs, you typically:

How many hours per week can you realistically dedicate to improving your health? (required)

What will happen if you do not change? (required)

Survey

Are you fully aware that the core component of Dr. Zaldivar's coaching involves progressive overload cardio and strength training, and are you cleared to participate in a structured exercise program? (required)

How convinced are you that exercise is far more powerful of a modality as compared to other programs such as supplements or medications? (required)

Do you believe there are other protocols that would work for you instead of this exercise-based coaching program? (required)

On the following scale, how committed are you? (required)

Please add any additional information that might be helpful to assess eligibility for this coaching program.

Address

Country

Address Line 1 (required)

Address Line 2

City (required)

State (required)

ZIP Code (required)

Number

This program focuses on physiological dopamine optimization through structured behavior change. It is educational and coaching-based in nature and does not replace therapy, crisis counseling, or psychiatric treatment. Meaningful results require consistency, personal responsibility, and implementation. By submitting this application, I acknowledge that outcomes depend on my engagement and follow-through. Due to the individualized strategy, intellectual property, and time investment involved, all coaching investments are non-refundable. I am applying because I am ready to commit, even when growth feels uncomfortable or motivation fluctuates.