Grow + Glow: Neural Identity Surgery™ Form
SECTION 1: IDENTITY + PERSONAL INFORMATION
Name
First Name
Last Name
Preferred Name
Email
example@example.com
Phone Number (with country code)
Please enter a valid phone number.
Country or residence
Instagram / LinkedIn Profile (optional)
SECTION 2: CURRENT LIFE + LEGACY POSITIONING
What do you currently do for work or business?
How would you describe your current identity? (Who are you known as right now?)
What legacy are you building or desiring to build in this lifetime?
What is your current estimated net worth? (If applicable)
Are you the primary decision-maker in your company or household?
SECTION 3: EMOTIONAL + GENETIC INHERITANCE
Do you believe you're carrying emotional or behavioral patterns from your family line? Please describe.
In what ways do you feel your inherited identity is limiting your success, love, or inner peace?
Have you ever done identity work, therapy, or trauma-informed healing? If so, what kind?
Are you aware of any patterns in your relationships, leadership, or self-talk that feel misaligned with who you're becoming?
SECTION 4: NEURAL SURGERY READINESS
Why do you feel you’re ready for Neural Identity Surgery™ now?
What are 1–3 non-negotiable outcomes you must experience from this transformation?
What would you no longer tolerate in your life, business, or love if your neural identity was redesigned?
What has prevented your healing or evolution in the past?
On a scale of 1–10, how committed are you to receiving a full transformation? (Provide as much detail as possible)
SECTION 5: FINANCIAL INVESTMENT + ENERGETIC CAPACITY
Which investment level are you prepared for? (Tiers 1-3: https://www.elsieblass.com/surgerysuite)
Please Select
Zoom Surgery + Post-Op Integration $100K
2-Day In Person Immersion Surgery + Extended Protocol $250-500K
Global Elite Neural Identity Transfer Surgery™ + Legacy Calibration $1M
Are you prepared to make this investment now, or would you require support (e.g., wiring, family office coordination, strategic planning)?
SECTION 6: INTENTION + INTIMACY
How do you envision your life, love, and leadership post-surgery?
What does “emotional elegance” mean to you?
Is there anything else you would like Dr. Elsie Blass to know before she reviews your application?
Submit
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