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Application for Acceptance
Welcome - whatever brought you to this point in your journey, I see you and celebrate you on this HUGE Step.
I invite you to fill out this application for enrollment consideration:
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* Indicates required question
Email
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Your email
First Name:
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Your answer
Last Name:
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Your answer
Address:
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Your answer
Phone Number:
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Your answer
Date of Birth
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MM
/
DD
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YYYY
Birth Time
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Time
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AM
PM
Birth Location
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Your answer
Why Now?
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Your answer
If accepted, what are you looking to gain clarity on or accomplish?
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Your answer
Are you committed to showing up and doing the work physically, mentally, emotionally, and energetically?
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Yes
No
What are the stories/wounds/pains/patterns that have caused you not to live up to your true potential thus far?
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Your answer
What is this costing you if you do nothing or stay in the same cycle?
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Your answer
What would your life look like if you addressed, cleared, or transformed this?
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Your answer
Are you willing and committed to invest energy (time and money) in yourself to achieve this?
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Yes
No
On a scale from 1-10, how WILLING and COMMITTED are you to stretch yourself physically, mentally, emotionally, and energetically for the sake of your dreams?
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1
2
3
4
5
6
7
8
9
10
Why me as your container holder/mentor/instigator?
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Your answer
Have you been in any self development or transformation programs before?
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Yes
No
If yes, what was it and how did it impact you?
Your answer
What is your profession/job/career?
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Your answer
What is your favorite food?
Your answer
Send me a copy of my responses.
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