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Blueprints "Your Life by Design" Application
This information is gathered for exclusive the exclusive use by Dr. Marcus Robinson and the Social Innovation Group and will not be shared, we take your privacy seriously.
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Email
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Your email
Full Name
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Your answer
Address
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Primary Phone
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Your answer
Email
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Your answer
Social Media (Should you want to share)
Your answer
Preferred Pronouns (Example: He/Him/His... She/Her/Hers...They/them/theirs)
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Your answer
Occupation
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Your answer
Avocation(s) (Hobbies or other Passions)
Your answer
Military Experience
Your answer
Are you in Therapy? If so, are you winning?
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Your answer
Has a medical professional ever recommended counseling or Therapy to you?
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Your answer
How do you behave under stress or pressure(especially tough situations)?
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Your answer
What do you most want to learn from this workshop?
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Your answer
What are some examples of your life achievements that make you proud?
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Your answer
What recurrent issues or problems consistently challenge your ability to meet your goals?
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Your answer
What barriers (reasons you can't) make progress towards your hopes and dreams?
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Your answer
What do you most want to be able to do as a result of attending this workshop?
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Your answer
What else do you want us to know and understand about you?
Your answer
If you are accepted into the program, are you committed to attending all three full sessions without fail? (Dates TBD)
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If you are accepted into the program, do you give us full permission to use your photo, likenesses, sound and other images of you as a result of your participation in the Workshop?
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