Participant Application Form

Program Application

Separation, divorce and uncoupling with compassion
Welcome.

I'd love to know a little bit about you and your hopes for taking this program. I am happy to hear any questions that you may have for me. We will use this inquiry form as a starting point to ensure that this program is a good fit for you.

Angela Walkley
Name

First Name Last Name
Email address
example@example.com
Phone Number
Please enter a valid phone number.
Your City/Town of Residence
What do you hope to get out of this program?
Describe briefly your break up situation. It does not have to be recent to harvest value out of going through a process of uncoupling and individuation.
What types of things are you doing now to support yourself through this difficult time?
Are you willing to commite to the following:
- Read the Conscious Uncoupling Book by Katherine Woodward Thomas
- Weekly 1-on-1 sessions with Angela
- Weekly Monday evening group sessions
- Journalling and answering weekly self inquiries
- To look into places of self responsibility and making lasting change to break patterns and move towards new supportive ways to be in relationship
- Program payment of $965
Yes No
Do you have any questions for me?
Your responses to these questions are confidential. I appreciate what you have been willing to share with me. Together in this program you will have a chance to transform your experience and move forwards.

After receiving your application I will follow-up regarding whether or not there is availability and to make sure that the program is a fit for you.
Payment by etransfer or PayPal to be made following confirmation of your enrollment.
Should be Empty:

Program Application