Braving Your Way through Life Transitions Registration Form

Welcome, I am delighted to begin this journey of learning and growing together.  Please complete this form and submit payment to secure your place in this program.  If you have questions please contact me at ValerieBrown95@gmail.com or 215-933-9978.

Your registration is complete once you have completed and submitted this form and made full payment.  Partial payment and incomplete registration forms cannot be accepted.  Payment of $395 per person may be made via Venmo at @Valerie-Brown-140

Email *
How did you learn about this program? *
Name (First and Last) *
Email Address *
Mailing Address *
Phone Number *
Preferred Pronouns *

Please describe your identity and culture (visible and invisible aspects of your identity and culture):

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What elements of your culture/identity are important to you that I should be aware of as we begin this program and coaching:

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Please describe your current life transitions:

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What are your short term (6 months or less) goals:

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What are your long-term (1 year or more) goals:

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Why is this meaningful to you?

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How will you know that you are successful in achieving your goals?

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What might interfere or interrupt your ability to achieve these goals?

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What is your preferred mode of learning?     Check all that apply:    
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Required

Access Question: Please describe any special needs that you might have.  We want to anticipate and meet your needs.

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