Circle Application

Name

First NameLast Name

Phone Number

Please enter your mobile phone number.Format: (000) 000-0000.

Email

e.g., office@kellyminor.com

How did you find the circle?

If referred to my private practice, by whom?

Do you have any mobility or dietary restrictions (e.g., dairy-free, gluten-free)?

Do you have any allergies or sensitivities (e.g., essential oils, flowers, pollen)?

Do you have any doubt about your ability to arrive at retreat 100% fragrance-free?

Do you have any questions regarding the application process?

Is there any information that you couldn’t find or easily access on the webpage?

Please provide details for any "yes" responses above.

Developmental History

What is the extent, if any, of your prior training in Acceptance and Commitment Therapy (ACT)? If you are a mental health worker, what is your therapeutic orientation?

Historically, what has been your commitment to personal development? Have you previously been engaged in any psychological work and/or spiritual practice? If so, provide a timeline and describe the primary themes you worked through. (Note. This question refers to the past. Later, you will be asked to describe your present-day practices.)

Personal History

Have you experienced any major traumas, life transitions, or losses in the past 5 years? If so, please give a brief description of the situation and its impact upon you now.

Have you ever been treated or hospitalized for any mental health condition (e.g., depression, anxiety, significant trauma)? If so, please give a brief description and timeline.

Present Day

What are the themes of your life at present? How do you spend your precious resource (e.g., time, energy)? What do you value and prioritize in your life currently? How does the circle fit?

Are you currently engaged in any psychological work and/or spiritual practice? If so, what are the primary themes you’re working on? If you are currently in therapy, does your therapist support participation in this circle?

Do you have any challenges or concerns with regard to joining a circle? (If so, what are they?) Do you have any desires or wishes with regard to joining a circle? (If so, what are they?)

Please feel free to write about anything else you wish Kelly to know.

The following statements describe the process for entering a circle. If you are accepted into a circle, then your signature below indicates your agreement to the following entrance procedures:

Initial Here Entering a Pre-Existing Circle. To prevent potential conflict-of-interest, Kelly will present my name (only) to the pre-existing members of the circle in writing. If any pre-existing member has concerns, then she will simply respond “Yes to conflict of interest” (with no additional information). In that case, I will not be invited to join the circle (with no rationale). In this way, the circle remains a place of safety and support for those already in it.

Initial Here Entering a Newly-Formed Circle. There is no way to prevent potential conflict-of-interest when gathering a group of women in circle for the first time. If I discover conflict of interest with another member of the circle, then I will discuss this with Kelly in private to determine best options.

I hereby certify that, to the best of my knowledge, the information provided above is true and accurate. I have read carefully and understand the Circle Application Form. By my signature below, I agree to its terms and conditions.

Name

First NameLast Name

Date

Signature