Rewire the Shadow - Application
This is the application to be apart of a truly transformative 8 Week intensive Journey guiding you to the depths of your fears, anger, sadness and limiting beliefs which are currently creating and governing the world you are living in.

This Program is not for just anyone, this program is for those who are truly committed to creating their ideal future. Who are dedicated to living a life of freedom, abundance, love and Purpose. In addition are committed to letting go of their past, their old self so they can create, become and be the person they want to be.

Take the time to really think about each question. Its Important for us to see if this program is right for you and you are right for the program.
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Email *
First Name - Last Name *
Phone Number *
Email *
Date of Birth *
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Marital Status *
Job Title/ Occupation
What's Going Well in your life currently?
What would you like to change?
What is it you feel like you need?
Please rate your satisfaction in the area of Emotions (1 low, 5 high)
Low
High
Clear selection
Please rate your satisfaction in the area of Relationships (1 low, 5 high)
Low
High
Clear selection
Please rate your satisfaction in the area of Sexuality (1 low, 5 high)
Low
High
Clear selection
Please rate your satisfaction in the area of Spirituality (1 low, 5 high)
Low
High
Clear selection
How much do you relate to this: Fear of Failure
Low
High
Clear selection
How much do you relate to this: Fear of Success
Low
High
Clear selection
How much do you relate to this: Fear of judgement
Low
High
Clear selection
How much do you relate to this: Fear of Rejection
Low
High
Clear selection
How much do you relate to this: Fear of Loneliness
Low
High
Clear selection
How much do you relate to this limiting belief: I’m not good enough
Low
High
Clear selection
How much do you relate to this limiting belief: I’m not worthy
Low
High
Clear selection
How much do you relate to this limiting belief: I can’t have what I want
Low
High
Clear selection
How much do you relate to this limiting belief: I don’t accept myself
Low
High
Clear selection
What are the biggest things that are stopping you from having and living the life you want?
Whats one thing you want more of in your life right now?
Whats one thing you want less of in your life right now?
List three things you are tolerating right now in your personal life?
Be Honest, How well do you keep commitments?
I don't keep them
I'm very committed
Clear selection
What are the biggest changes you want to make in your life in the next 3 months?
What are the biggest changes you want to make in your life over the next 3 years?
What is the hardest thing in your life that you have had to overcome?
On a scale of 1 to 5 with 5 high, rate the quality of your life today
Clear selection
If you reach the age of 95 and continue to live your life and order your time the way you are right now, what regrets do you think you will have? (Tip: complete the statement “I wish I had...”) Do not include things from the past—only things you will regret if you continue your exact present path.
List five things that you’re personally tolerating or putting up with in your life at present. (Examples: information you can’t find, clutter, rude friends, tight shoes, dented car, job dissatisfaction, dead plants, broken equipment, cranky people in your life etc.)
What are your primary stressors? (What stresses you out?)
On a scale of 1 to 5, 5 high, rate the amount of stress in your life right now
Clear selection
Are you under medical/therapeutic treatment? Yes or No? If yes, for what condition?
List any medications (including aspirin) and nutritional supplements you are taking
Are you Currently taking any illegal drugs or do you have any addictions?
Do you feel like you are in danger of self harming?
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