Scholarship Request
Thank you so much for your interest in this program.  

Take a minute, drop into your heart and fill this out from a mindful place of reflection.  This is as much for you as it is for me.  Give yourself the gift of this moment to tap into your authenticity, your voice, and what you really want.

Thank you and know all info is confidential to you and me.
Email *
Name *
Address
Phone number
Emergency Contact Name, Phone, and Relationship *
What's going on in your life that brings you here?
What do you want to change or improve now?
What about your current situation upsets you the most?  And how do you know you are upset?
What do you feel is holding you back?
If you had a magic wand, what your life look like? What would be different?
Have you worked with a Coach or Therapist before?  What did you get from and what worked, what didn't work?
Have you ever been given a mental health diagnosis?   Please share and let me know how you feel about that diagnosis.
Do you have epilepsy, seizures, asthma, or other severe medical conditions?
Is there anything else you want to share?
Why do you feel this scholarship is perfect for you?
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