STEP 1

KWEIBA MEDICAL® Coaching Program Application

Confidential application for elite professionals seeking high-impact, root-cause burnout recovery.

“You’ve carried the weight. We’ll help you recover your power, with precision, privacy, and science.”

To get started please complete the form below:

SECTION 1: WHO YOU ARE

Full Name *

Email Address *

City + Time Zone

Your Role or Title

Current status:

Working full-time

On medical or personal leave

In transition

Other

SECTION 2: WHAT YOU’RE EXPERIENCING

Which of the following are currently true for you? (check all that apply)

I’m exhausted, even after rest

I feel emotionally flat or numb

I’ve lost focus or mental clarity

I’m silently struggling behind a high-functioning image

I’ve tried to slow down, but it hasn’t helped

I’m afraid this is costing me more than just energy

What have you already tried to address your burnout? (check all that apply)

In your own words: What do you believe is keeping you stuck?

SECTION 3: YOUR READINESS

Doing this work will require emotional honesty, nervous system recalibration, and structure. How ready are you to engage deeply and consistently in this recovery process?

I’m exploring but not fully committed

I’m ready—but I may need help staying accountable

I’m fully committed—I’ve waited too long for this

Our recovery experiences are high-touch, medically informed, and built for women in leadership who require discretion, structure, and real results. Most clients invest between $5,000 and $25,000 depending on the level of support. How would you describe your financial readiness for this level of care?

I’ve already allocated funds for recovery and want to begin

I’m ready to invest if the solution is right for me

I’m ready to start with a payment plan

I’d need to plan and prepare, but I’m open to the conversation

I’m not ready for that level of investment at this time

Why now? What’s made you reach out at this specific moment?

If we could help you recover fully, quietly, and without sacrificing your career—what would success look like for you?

SECTION 4: ALIGNMENT

Our work is clinical-grade, trauma-informed, and private. It’s not therapy or treatment—it’s strategic nervous system recovery for high-functioning professionals. Do you understand and consent to this framework?

Yes

I have questions

Anything else you’d like to share or ask? (Optional)

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