Grow + Glow: Neural Identity Surgery™ Group Form
SECTION 1: IDENTITY + PERSONAL INFORMATION
Name
First Name
Last Name
Preferred Name
Email
example@example.com
Is this for you, a group or your team?
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 or retired?
How would you or your group describe your current identity? (Who are you known as right now?)
What legacy are you building or desiring to build in this lifetime?
Are you the primary decision-maker in your company or household?
SECTION 3: EMOTIONAL + GENETIC INHERITANCE
Do you believe you're or your team is carrying emotional or behavioral patterns from your family line? Please describe.
In what ways do you or your group feel your inherited identity is limiting your success, love, or inner peace?
Have you or your group ever done identity work, therapy, or trauma-informed healing? If so, what kind?
Are you or your team/group 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 or your group feel you’re ready for Neural Identity Surgery™ now?
What are 1–3 non-negotiable outcomes you and or your group must experience from this transformation?
What would you or your group no longer tolerate in your life, business, or love if your neural identity was redesigned?
What has prevented your or their healing or evolution in the past?
On a scale of 1–10, how committed are you and your group to receiving a full transformation? (Provide as much detail as possible)
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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