Client Application
  • All clients who wish to be considered to work with me in my 6 month Alignment Mentorship program, "The Perfect Design" are asked to take some time, tune inward and really reflect on your answers so I can be of service to the most deeply aligned individuals. The information collected will be kept confidential. Mahalo!
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Name *
Age *
Referred By *
Relationship Status *
Occupation *
1. Previous transformational experiences *
(i.e. workshops, therapy, coaching, counseling, 12-step, etc)
2. What are your current spiritual practices and affinities? *
(Formal or Informal)
3. Describe briefly the most elated/joyful times in your life. Please include what it was about these times that made you so happy and what they meant to you. *
4. Describe briefly the most traumatic experiences in your life: *
(Please include any of the following that have happened to yourself or a loved one/family member: Absent parent(s), divorce of parents, physical, sexual or emotional abuse, adoption, miscarriages, early death, suicide or attempted suicide, prolonged illness, major injuries, mental disorders, public shaming, religious trauma, war etc)
5. In what areas in your life (if any) do you struggle to appreciate, nourish, or value yourself? *
6. What is it you’d like to let go of, or heal during our time together? *
7. What is it you’d like to receive through our time together? *
8. What might stop you from receiving this? *
9. What fears, if any, do you have about working together? *
10. Is there anything else you’d like me to know about you? *
Health and Well-being
I care about you and your needs and do my very best to be sure that us working together is a good fit for us both.
1. Do you have a history of drug or alcohol abuse? If yes, are you still using? Please describe in detail: *
(Please know, because of the deep inner work you will be doing, recreational drugs and alcohol are not permitted and you are expected to arrive sober.)
2. Are you currently in therapy, counseling, or coaching? If yes, what kind and how often? *
3. Are you currently taking any psychiatric medication? If yes, for what condition? What kind and what dosage? *
4. Have you struggled with, been diagnosed with, or hospitalized for any of the following conditions in the past 10 years? If yes, please describe in detail. *
(Include whether or not you've been diagnosed or hospitalized within the last year) Conditions include: Psychosis, bipolar disorder, major addiction, self-injury or suicide attempt (for example cutting), PTSD or panic attacks
Cell Phone Number *
I, the undersigned, certify that all of the above information provided is true and complete. Furthermore, I understand that this type of work may be mentally, emotionally, and physically demanding. Therefore I have disclosed, to the best of my knowledge, all relevant information about my health and well-being that might have a bearing on my participation as I understand them. I understand that the information provided herein will only be used to determine if it is appropriate for me to participate in this work. This information is my confidential information and it will be used to assess whether or not this work is aligned for me. I understand that I must keep my mentor informed of any changes to my medical history during our time working together.
Signed *
Date *
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