Apply for R2R

Please complete and submit the questionnaire below to apply for Road to Remission with Callie!

To learn more about what Callie offers, click here.

This application form acts as a serious inquiry expression.

Please do not fill it out if you are not serious about working with me.

It's important you fill this out accurately and as detailed as possible to ensure a good fit from both ends. Once I review the application form and assess that our working together is a good fit, I will contact you to discuss the next steps in the process.

How did you learn about my services?
Facebook
Instagram
Tik Tok
Pinterest
Reddit
PHS Canada
Medical Professional
Other

What is your worst IC symptom? (may choose more than 1)

BurningPainful urinationFrequencyUrgencyPelvic pain/pressurePain with intercourseOther

What have you tried in the past to lessen your IC symptoms?

AmitriptylineHydroxyzineElmironHydrodistentionDesert Harvest Aloe VeraOther SupplementDiet ModificationsPelvic Floor Physical TherapyStress ManagementInstillationsTreatment of Hunner's LesionsNeurostimulationOther

Do you have 3 months to dedicate to identifying your dietary triggers?

YesNo

R2R was created to support you in identifying your IC triggers & minimizing your IC symptoms. Knowing it will require a time, emotional & financial investment, how prepared are you to take action now, & invest $3,997 to transform your health & life?
I have access to the financial resources to invest in my health right now and I'm ready to get started (Pay in Full $3,997)
I have access to the financial resources to invest in my health right now and I'm ready to get started (3 Month Payment Plan of $1,333)
I have access to the financial resources to invest in my health right now and I'm ready to get started (6 Month Payment Plan of $667)

How would you like me to reach out to you with next steps?

InstagramTikTokFacebookEmail

I would like to receive future communications

I agree to the GDPR & CCPA Terms & Conditions

I confirm that I am at least 16 years of age or older

I have read and accept any EULA, Terms and Conditions, Acceptable Use Policy, and/or Data Processing Addendum which has been provided to me in connection with the software, products and/or services.

I have been fully informed and consent to the collection and use of my personal data for any purpose in connection with the software, products and/or services.

I understand that certain data, including personal data, must be collected or processed in order for you to provide any products or services I have requested or contracted for. I understand that in some cases it may be required to use cookies or similar tracking to provide those products or services..

I understand that I have the right to request access annually to any personal data you have obtained or collected regarding me. You have agreed to provide me with a record of my personal data in a readable format.

I also understand that I can revoke my consent and that I have the right to be forgotten. If I revoke my consent you will stop collecting or processing my personal data. I understand that if I revoke my consent, you may be unable to provide contracted products or services to me, and I can not hold you responsible for that.

Likewise, if I properly request to be forgotten, you will delete the data you have for me, or make it inaccessible. I also understand that if there is a dispute regarding my personal data, I can contact someone who is responsible for handling data-related concerns. If we are unable to resolve any issue, you will provide an independent service to arbitrate a resolution. If I have any questions regarding my rights or privacy, I can contact the email address provided.

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