Bring Back the Love

Name*

First NameLast Name
Email*
example@example.com
Current place of residence*

Street Address

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
How long have you been with your partner?
Describe your relationship and the challenges you currently face in your own words?
What are you hoping to get out of the programme?
Have you had difficult emotional experiences in your life that you feel still impacts you today? If yes, please describe in your own words.
How did you learn about this program?
Is there anything else that may be important to know about you?
Agreement & Disclaimer

I agree that my decision to participate in Bring Back the Love group coaching programme is a personal decision. There are no guarantees as to the specific results of the programme as it is entirely dependent my own personal circumstances and how I engage with the programme. I understand that this programme is not designed to deal with deep-seated psychological disorders. If I experience any psychological difficulties, severe depression, altered states or any other strong psychological state, I will consult my GP for a referral to a relevant specialist.

I understand that information shared in this programme is confidential and cannot be given out without the permission of the group facilitator (Maya Vaughan). I understand that all materials used in this programme are confidential and are the property of the course provider (Maya Vaughan).

By submitting this form, I agree to be added to mayavaughan.com mailing list. You have the right to opt out at any time after completion of the programme.
Signature*

Clear
Payment

Bring Back the Love – 5-week intensive group coaching programme
Select your payment fee:

Webinar discounted fee: £295.00 (available until Sunday 29th)Early Bird offer: £345.00 (available until December 15th)Full payment: £395.00 (available until January 7th)
Type payment amount

prevnext( X )
GBP

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty: