Professional Referral

Emerging Lotus & Lotus Rising Referral Form

A Mindfulness-Centered Healing Journey
Thank you for providing a referral to the Emerging Lotus or Lotus Rising Program, a mindfulness-centered journey designed to nurture presence, resilience, and self-awareness.

Our programs offers a gentle and supportive space for individuals to explore mindfulness, emotional balance, and community connection.

Please complete the form below to share your referral. This form is non-clinical and focused on readiness, interest, and strengths. Once submitted, a member of our team will reach out to the referred member to schedule a brief welcome conversation.

Only use this form if you are a therapist, counselor, mentor, or community professional.
Referring Person's Information
Name*

First NameLast Name
Organization or Practice Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Relationship to the person being referred
Individual's Information
Name*

First NameLast Name
Age*
Which program are you referring to?*

Emerging Lotus Program (age 18-24, women only)Lotus Rising Program (age 25-30, co-ed)
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Reflection from Referral

This section invites you to share your reflections on why you feel this individual would benefit from the Emerging Lotus or Lotus Rising Program. There are no right or wrong answers please share from the heart.
What strengths or qualities are you aware of that would help them benefit from a mindfulness-based experience?*
How might mindfulness, reflection, and community support their current journey?*
Readiness for Mindfulness and Growth
Please check all that apply. These indicators simply help us understand where they may be on their journey.*

Shows curiosity about mindfulness or healing/holistic practicesWould benefit from a supportive, community-based groupDemonstrates openness to self-reflection and personal growthMay need structured, positive support for emotional balanceOther. Please discribe below
Other. Please share anything else you would like us to know.
I have discussed this referral with them and they have given permission for An Ounce of Kibou to contact them directly.*

YesNo
Should be Empty:

Emerging Lotus & Lotus Rising Referral Form

Referring Person's Information

Individual's Information

Reflection from Referral

Readiness for Mindfulness and Growth