Initial Intake Form

Full Legal Name *

Email *

Phone *

Date of Birth (MM-DD-YYYY) *

At what age did you feel your best? *

What is the main concern, symptom, or goal that led you to consider working with Dr. Gladden? *

Which statement best describes your mindset around health optimization? *

I am comfortable with advanced testing, data-driven decisions, and personalized medical strategies

I prefer conventional care and minimal intervention

I am unsure and want guidance before choosing an approach

Dr. Gladden’s work is long-term, durable, and relationship-based. Most clients work together for a minimum of 6 months. *

Yes, I am looking for a long-term solution

I am open to long-term care if the approach and outcomes make sense

No, I am only interested in short-term or one-time support

What does success look like for you 12 months from now? *

How urgent is it for you to address this right now? *

This is a top priority and I am actively seeking a solution

I know this needs to be addressed soon, but I am not ready to act yet

I am currently researching and comparing options

Dr. Gladden’s clinic is located in Dallas, TX. Much of the work can be done remotely once an in-person assessments are an important part of the program. If we work together, are you willing to visit Dallas at least twice per year? *

Yes, I can visit Dallas TX for a minimum of 2 days (twice a year)

No, I’m only interested in virtual support

Some clients may need more visits per year depending on their situations.

Our programs typically begin at $35,000 - $50,000 and can extend higher depending on diagnostic and care needs. If this is the right fit, how prepared are you for this level of investment? *

I understand that care is provided on a self-pay basis and is not billed to insurance.

What concerns, hurdles, or unanswered questions might prevent you from moving forward after this conversation? *