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Person-to-Person Program - Application Form
The Person-to-Person Program connects individuals in the Attitudinal Healing global community who wish to meet one-to-one for mutual support utilizing the concepts and Principles of Attitudinal Healing. The means of communicating, the frequency, and the duration of the relationship are up to the individuals. This is not a mentoring situation. This is peer support. Both participants are equals, though not necessarily matched because they are facing the same issue. Both are teacher and student. Both are there to speak and listen with open hearts. Both are there for each other’s healing. The one-to-one participation has the potential for deeper, more vulnerable communication, free of the time restraints one sometimes finds in a group meeting. Participants often find that though the circumstances causing their challenges might not change, the time spent together brings a different awareness; a time when one’s perceived problems subside.
To participate in the Person-to-Person Program, please complete and submit this form. Someone will contact you to schedule an intake interview within one week of receiving your application.
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Email
*
Your email
Full Name
*
Your answer
Phone Number
*
Your answer
Physical Location (City, State, Country)
*
Your answer
My reasons for participating in Person-to-Person are:
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Your answer
I am currently under the care of a physician for a condition currently impacting my life.
Yes
No
Clear selection
I am currently under the care of a psychiatrist or therapist for a condition currently impacting my life.
Yes
No
Clear selection
The best way to contact me to schedule an intake interview is:
Phone
Text
Email
Other:
Clear selection
I am available to communicate with a Person-to-Person partner in the following ways
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Phone
Text
Video Chat
Email
In Person
Required
I am familiar with Attitudinal Healing concepts and practices
Yes
No
Other:
Clear selection
I have participated in the following AH activities:
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Peer Support Groups
AH Workshops
AH Facilitator Training
Read Jerry Jampolsky's Books
Other:
Required
I am currently a member of an AH group facilitated by (name of facilitator):
Your answer
Please describe any other experience with Attitudinal Healing
Your answer
Other questions or comments
Your answer
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