Helping Minds, Mending Hearts Registration Form
Participant Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (WhatsApp Number)
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Age (Must be 21-35)
*
Preferred timings on Saturday/Sunday (Please include timezone):
*
What inspired you to join the Helping Minds, Mending Hearts Brotherhood Mentorship Program?
*
How do you view the relationship between mental health and Islam?
*
Have you previously participated in any mental well-being or mentorship programs? If so, please describe your experience.
What are the biggest mental or emotional challenges you currently face?
The program consists of 13 group sessions and one one-on-one coaching session. Are you able to commit to attending all sessions?
*
Yes
No
Maybe
The program is designed to be a judgment-free, supportive space. Should you be selected to participate, you will be requested to sign some paperwork ensuring confidentiality and maintaining program expectations. Are you able to commit to fulfilling those requirements and signing the paperwork? (If not, you won't be able to proceed to next steps)
*
Yes
No
The program costs $99.99 early bird, and $150 regular price. The first two sessions are completely FREE. If the program feels aligned after the first two sessions, I will pay the full amount to participate in the program. Any payment plan/discount arrangements will be agreed upon with the coach.
*
Yes
Submit
Should be Empty: