HealMobile Voyage Application & Agreement
Alignment Coaching & Counsel | Application for Services to be Rendered by Dr. Niamo A-Raheem Muid
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Email *
Full Name *
Cell or Preferred Phone # *
Homes Address - Street, City, State, Zip *
Occupation / Livelihood / Retired? *
Business, Organization, Faith-Based Community or Spiritual Pathway name (if applicable, or put NA) *
Website
Marital Status - Single or Couple, etc.
Head of Household? *
# of People in Household; how many children and/or elders? *
Date of Birth
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Contact Information - Email, and favorite Social Media *
Which platform(s) do you prefer for sessions with The HealMobile? Check all that apply. *
Required
Education (Mark highest levels that apply) *
Required
Your Priority - On a scale of 1 - 5 with 5 being Most Important, assign a number to each area: 

- Money-Career Achievement (MCA)
- Improving Health (H)
- Increasing Spirituality (S)
- Improving Relationship(s) (R)
- Changing Lifestyle (L)

Example: H - 5, MCA - 4, L - 3, and so on.
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What makes you proud, when you look back at your life? *
Share your expectations. Name 1 or 2 outcomes you hope to experience from working with me.
PLEASE READ Alignment Coaching and Counseling Agreement

By signing this form, you agree to our covenant while we are in the coaching or counseling relationship. Should we agree to work together, an overview of the specific opportunity is provided below separately. If we have already made an agreement, this serves as confirmation of same.
   
Our Relationship 
I hold holy my connection to you. This holistic connection forges a sacred relationship. I pledge to give you my full attention while we are in power-partnership. I receive Spiritual Guidance for myself as well as supervision of my professional work, so that I am less likely to transfer my issues and more likely to help you transform yours.                  

Although I believe it is appropriate at times to discuss psychological and relational difficulties in the context of mentorship as Coach or Counsel, I am not a psychotherapist, nor do I provide such services. 

Similarly, you recognize that coaching and mentoring do not constitute financial advice, and any decisions and actions you may take in that regard are done without my help or recommendation and are purely your responsibility. 

I am a womb-centric coaching specialist, Reiki (energy hand-healing) master teacher, spiritual aromatherapist, and ordained holistic minister-practitioner with a health directive from Lightwing Center (NJ), trained to use pure oils for anointing and holistic alignment. 

Any of my tools and holistic training may be offered to enhance our power-partnership and relationship. Acceptance or nonacceptance of any tool or technique is not construed by me as a rejection of the coaching and mentoring relationship. My doctorate in gender and human rights emphasizes the right of everyone to experience the joy of full, holistic human expression that appreciates and enhances our relatedness and especially takes care of the special needs of women and their families.

Confidentiality
I will hold our conversations in strict confidence. Our time together is sacred. I will not reveal the content of our conversations unless I am required to do so by law or court order. You are free to share whatever you choose about our talks with anyone. To honor your personal spiritual covenant, if you have one, I ask that you let your Elder or Spiritual Advisor know you are working with me as an Alignment Coach and Holistic Cultural Counselor. I follow the best ethical principles of all the world’s scriptures.

Agreed to and signed (fill in your name), 
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FEES FOR SERVICES
-Optimum scale=optimal service; flex scale possible. 
-PREPAYMENT (PP) gets a lot of Love. 
-Stated amounts are guaranteed for 12 months. 
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Required
PREPAYMENT INFORMATION
By choosing a method below, you are agreeing to pay for your session(s), as the above describes. You will get a receipt for payment. Future payments can be made via a different choice if necessary.

If no Prepayment is checked, the meeting is your free exploratory meeting. This list will be emailed if a flex payment schedule is agreed upon.
BOOK APPOINTMENTS HERE. 

A confirmation notice will be emailed. Special access considerations? Let me know below or write NA.

I have found that a series of sessions works best, or the deeper impact of the work may not be experienced. Thank you for considering a longer-term partnership. 

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This signed Application Form and Agreement entitle you to Prepayment and Cash Payment Discounts. The Agreement starts on the date of your submission of the completed form. THANK YOU, ASANTÉ SANA, SHUKRAN LAKA. 
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