Practitioner Mentorship

Application Form

Please complete the form below to help us understand your goals, background, and how we can best support your development.

All information is held in the strictest of confidence according to our Privacy Policy.

Name

First Name

Last Name

Preferred Name

If different from the first name above.

Date of Birth

YYYY

Gender

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How were you referred to Revital Health?

What is your current practitioner status?

What is your primary discipline/specialty (e.g., women's health, mental health, integrative medicine, etc.)?

How many years of experience in the industry have you had (if practicing)?

Are you currently seeing clients/patients?

Briefly describe your current clinical setup or practice (if applicable):

What are your primary goals and objectives that you would like mentorship support with?

What are the biggest challenges you currently face in your business?

Are there any specific areas of your business where you are seeking guidance (e.g., product development, marketing, client management, etc.)?

Are there particular skills or knowledge areas you wish to develop (e.g., health optimisation technology, onboarding staff, social media strategy, etc.)?

Have you previously worked with a mentor? If yes, what worked well and what didn’t?

What is your desired start date for the mentorship program?

YYYY

What is your preferred duration or commitment with the mentorship program?

Which mentorship program are you applying for?

What is your availability for mentorship sessions?

(Days/times that generally suit you)

Is there anything else you would like your mentor to know before starting the mentorship?

If you have designated a third-party to pay for your mentorship sessions, please provide their email below:

Leave this question blank if not applicable.

Declaration and Acknowledgement

By enrolling in the Practitioner Mentorship Program at Revital Health, I confirm that I understand and agree to the following terms: This Mentorship Program involves a 4-month commitment and constitutes a lock-in contract (Mentorship with Jodi Duval only). I acknowledge that payment for the Mentorship Program is non-refundable, regardless of participation or circumstances that may arise after commencement. I understand that I will be invoiced prior to the initial onboarding session, and payment is required to confirm my placement in the program. If I wish to discuss or arrange a payment plan, I acknowledge that it is my responsibility to contact Revital Health before onboarding by emailing info@revitalhealth.com.au. I agree to engage fully in the mentorship process and uphold a respectful, professional relationship with my mentor and the Revital Health team. By proceeding, I affirm that I have read, understood, and accept these terms in full.