Apply to work with us

This isn’t just a program. It’s a transformation.

At the

International Pause Institute

, we work with individuals who are ready to take bold, empowered steps toward optimizing their health, hormones, confidence, and vitality. This is for people who don’t want a quick fix — but a deep, root-cause reset of the body, mind, and spirit.

That’s why our signature programs are by application only.

We give every client personalized, concierge-level attention — and we only take a limited number of participants each month to ensure the highest level of care.

🚨 Who This Is For

You’re 40+ and feeling off, burnt out, bloated, or blah

You’ve tried doctors, diets, or supplements… with little long-term success

You’re serious about feeling great, looking radiant, and performing at your best — in every room of your life

You’re ready to invest time, energy, and finances into your transformation

You’re done with band-aid solutions and want answers, support, and results

❌ Who This Is Not For

You’re looking for a one-size-fits-all fix or a quick prescription

You’re not ready to make lifestyle changes

You’re not open to functional or integrative medicine

You’re expecting insurance to cover this

You’re not ready to invest in yourself right now

💌 If You’re Ready, Let’s Talk

We’re excited to support high-achieving women and men who want more energy, better sleep, hormone balance, gut healing, sexual vitality, and lifelong confidence.

👉 Please complete the application form below. If we determine you're a good fit, we’ll contact you to schedule a consultation and discuss the program we believe best suits your needs. Regardless of the outcome, we’ll ensure you hear back from us. Due to the high volume of applications, our response time may take up to a month. To avoid missing our email, please check your spam folder and add [email protected] to your trusted contacts. Thank you for your patience!

International Pause Institute

Intake Application

Thank you for your interest in our programs—we’re thrilled to get to know you better! Take a few moments to fill out our application, and we’ll help match you with the perfect program to achieve your goals. Once we review your information, we’ll reach out with the next steps if you’re accepted. We’re so excited to partner with you and start building your best life together—why wait?

Before you dive in, note that this application is designed to give us a full picture of where you are and where you want to go. It takes about 30-60 minutes to complete, and progress won’t save—so make sure you have time to focus or bookmark this page and come back when you're ready! Let’s get started!

First Name

Last Name

Address

Street Address

City

State

Country

Postal code

Prefered Phone *

Cell Phone *

Email *

Date of birth *

Birth Sex

Male

Female

Other

Prefered Pronouns

He/him

She/her

They/them

Other

How do you identify (ie race, ethnicity, religious group, nationality, other)

Pharmacy Information

Pharmacy Name

Pharmacy Street Address

Pharmacy Town

Pharmacy State

Pharmacy Zip Code

Pharmacy Phone Number

Preferred Mode of Contact

Contact Consent

You give us consent to leave messages:

Other location to leave message. Please indicate "contact us" only vs detailed message

You may release sensitive information to the following individuals:

Multi Line 35lk

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

While we do not accept insurance and are out of network with all providers, providing your insurance information can help streamline the process for prescribing medications, ordering radiology tests, and coordinating other therapies.

Primary Insurance Name

Insurance ID

Insurance Group Number

Primary Insurance Address

Primary Insurance Town

Primary Insurance State

Primary Insurance Zip Code

Primary Insurance Phone Number

Name of Responsible Party of Primary Insurance

Date of Birth of Primary Insurance Responsible Party

Secondary Insurance Group Number

Secondary Insurance ID

Secondary Insurance Street Address

Secondary Insurance State

Secondary Insurance Town

Secondary Insurance Zip Code

Secondary Insurance Responsible Party Name

Secondary Insurance Phone Number

Secondary Insurance Responsible Party Date of Birth

Medical History

I am most concerned with the following today: *

My top 3 health goals/expectations are: *

Second health goal/expectation

Third health goal expectation

I currently have or have been diagnosed with the following medical conditions:

Other Cardiovascular History

Other Neurologic History

Other Endocrine History

Other Reproductive History

Other Gastrointestinal History

Other Musculoskeletal History

Other Respiratory History

Other Autoimmune/Immune History

Other Cancer History *

Other Skin History *

Other Urinary History *

Other Blood History

Other Medical History Not Previously Asked

Other Eye History

Surgical History

Other Surgical History *

Family History

Please list other family history here along with who in your family had the condition ie. mother,father, maternal grandmother, maternal/paternal aunt....

Allergies

Other Drug Allergies *

What reaction happens with your allegy ( rash, swelling, anaphylaxis)

Other allergies not listed above and include what happens

Diet

Other

Other food sensitivities/allergies

Exercise

Other exercise history

Other Exercise History explain further on type of exercise performed *

Other Exercise length

Other Exercise Limitations *

Would you like support with exercise planning *

Yes

Indifferent

Rather not answer

Sleep

Other Sleep History

I go to be at this time:

I wake up at this time:

I need an alarm clock to wake me up

Yes

Other sleep habits or strategies

Work

Other work situation

My business/line of work/career is:

Other how I feel about my work

Finanicial

I have the following beliefs about money *

Money is the root of all evil

Money is stressful

There is a finite amount of money in the world

We should take from the rich and give to the poor

Money is a tool to help others and do more good in the world

Money is a tool for me to support my family and things I believe in

More money can always be made

The life is filled with opportunities to make money

Other

Other beliefs surrounding money

Other life event

I am currenlty working within a monthly budget/financial plan?

Yes

I am trying to get more consistent

How do you feel about investing in your health and wellness? *

It is a top priority

I want to but I am hesitant

I am unsure if it is worth the cost

I struggle to spend money on myself or my health

If my health concerns were guaranteed to be addressed I would be willing to spend a maximum of the following to get those results ( the following question will not limit your program access but will help us to better tailor you program to fit your budget) *

Cost is no barrier—whatever is necessary to achieve the desired outcome.

The amount of a luxury car ( $55,000-$100,000)

The amount of a kitchen renovation ($30,000-$50,000)

The amount of a nice week long vacation ($10,000-$20,000)

The amount of a luxury purse ( $5,000-$9,000)

The amount of a nice weekend get away ($2000-$4000)

The amount of a cell phone ( $800-$1800)

The amount of a nice dinner out ( $200-700)

I don't have the money to spend on myself right now

Other payment type

Are you the primary decision maker for financial decision of your health? *

Yes

I share decisions with a partner

Other

Financial health decision making other

Would you be interested in any of the following programs if they are available?

Couples programs at discounted rate

Group only programs at discounted rate

Payment plans

Scholarships

Hobbies

List hobbies *

Community

Other community involvement

Stress Reduction

Other stress reduction practices *

Spirituality

I have a spiritual practice

Yes

I am not sure

Explain your spiritual practice

Review of Systems

The following questions refer to symptoms you have currently or within the last 3 months

Other general symptoms

Other Skin, Hair, Nail Symptoms

Other Vision or Eye Symptoms

Other ear, nose, throat symptoms

Other Respiratory Symptoms

Other cardiovascular symptoms

Other gastrointestinal symptoms

My stool consistency is often: *

Type 1 hard separate lumps, like rabbit droppings

Type 2 sausage shaped, with lumps or grape like clusters

Type 3 sausage shaped with cracks on the surface

Type 4 sausage or snake like, smooth, soft, consistent

Type 5 soft blobs with clear gut edges

Type 6 soft, fluffy, like porridge, ragged edges

Type 7 watery, no solid pieces

Other genitourinary symptoms

Other Neurologic Symptoms

Other mental health symptoms

Other musculoskeletal weakness

Other endocrine symptoms

Other hematologic/immune symptoms

Other breast symptoms

Programs:

I am interested in the following programs:

Whatever I need to feel better

Pause Protocol: Hormone Optimization

Play Program: Sexual Wellness

Fast Forward: Weight Loss and Body Optimization

Rewind: Aestethic and Cosmetic Procedures to Look my Best

I am not sure

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

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This isn’t just a program. It’s a transformation.

🚨 Who This Is For

❌ Who This Is Not For

💌 If You’re Ready, Let’s Talk

Institute

CUSTOMER CARE

CUSTOMER CARE

NEWS

LEGAL