CDHS Mentorship Program Application

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Please complete this form. Please make sure the spelling of your name is correct, addresses are accurate and DOBs are complete.

Email *

What is Today's Date? *

YYYY

Preferred Name *

(As you want to be addressed)

First Name *

(Legal First Name)

Middle Name

(Legal Middle Name)

Last Name *

(Legal Last Name)

Date of Birth *

MM/DD/YYYY

Phone Number *

111-111-1111

Full Address *

Address, Apt #, City, State, Zip Code

Emergency Contact Name(s) *

Add as many as you like, only one (1) will be added to your booking

Emergency Contact Phone *

Add as many as you like, only one (1) will be added to your booking

Are you interested in group or individual mentorship? (Select One) *

Individual

Group

What certifications do you have? *

What trainings have you taken in Birthwork? *

What was your experience with spirituality growing up? *

What is your spiritual practice today?

Have you had any spiritual initiations?

Yes

Clear selection

Photo/Video Release Authorization *

I authorize Cypress Doula & Healing Services, LLC, as well as any of its representatives and employees the right to take photographs of both me and any property in connection with the above-identified subject. I authorize Cypress Doula & Healing Services, LLC, to copyright, use and publish the same in any means deemed necessary including but not limited to print, electronic, or transferring of image. I agree that Cypress Doula & Healing Services, LLC has permission to display such photographs of me with or without my name and for any lawful purpose, including but not limited to such purposes as publicity, illustration, advertising, and web content. If participating party is a minor in the parent or guardian must provide consent for release of such photo on the terms above.

Yes

You can take pictures but don't share publicly please.

Once registered, you will receive an response in 24-48 hours by email to set up a 15 min interview. Please contact Rafeal Newport-Hewitt MA, Professional Doula & Spiritual Healer at Phone: (916) 629-4844, Email: CypressDoula@gmail.com, Website: CypressDoula.com, Facebook: Cypress Doula & Healing Services

Send me a copy of my responses.

Submit

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