Secure Love Info Form

1
Name* This field is required.
First Name
Last Name
2
What age bracket do you fall into?
16-19
20-24
25-29
30-35
35-39
40+
3
What timezone, city and country are you in?Please use the format for example "Chicago, Illinois CST" or "Brussels, Belgium CET"
4
Call times are Monday 12:30 EST or Wednesday 8pm EST. Can you make it live?*This is MONDAY 9:30am LA | 12:30pm NYC | 17:30 London | 18:30 Berlin* *This is WEDNESDAY 5pm LA | 8pm NYC | 1am London | 2am Berlin*
Yes I can for either
Might miss 1-2 with either
I CAN do the daytime not evening.
I CAN do evening but not day time.
Neither work for me, I'll do the replays
Neither work for me and I don't want to do replays
Other
5
We're diving in - Tell me about your personal development journey so far. Books you've read, podcasts you binge, topics that have been front of mind for you, programs you've taken etc. Even if it feels sporadic, I want to know what floats around your mind :)* This field is required.
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6
What's your relationship status? Do you have children?
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7
Briefly describe your relationship to your parents and please include if they are still living.
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8
Describe your biggest challenges (up to 3) that you are ready to work on* This field is required.
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9
Describe where you want to be * This field is required.
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10
How committed are you to getting there?
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11
How do you hope a program about inner work, and attachment style can change your life?
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12
Instagram handle* This field is required.
13
Best email address* This field is required.
14
Submit your deposit (which will be subtracted from your total tuition cost).This non-refundable deposit will hold your spot for Secure Love! If you are accepted I will send you the next steps including options to complete your tuition payment. If you are not accepted for the program, you will be informed and your deposit will be sent back to you. ❤️ If the timezone availability you listed is not the time of the program you will also be refunded.
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