Clone of Holy Spirit Heal Her Application

Application Form

Please fill out the form as honestly and thoroughly as possible.
Full Name*

First NameLast Name
Age
Address*

Street Address

Street Address Line 2

CityState / Province

Country
Phone Number*

Area CodePhone Number
E-mail
example@example.com
SingleMarriedDivorcedRather not say
Number of children
How would you best describe your belief system?

ChristianMuslimAtheistOther

How would you rate your satisfaction with your spiritual life?

	1	2	3	4	5

1 is Worst, 5 is Best

Are you currently being treated for any of the following?

DepressionAnxietyADHDAutismOther
Please share briefly, any current or past treatments for mental illnesses.
How did you hear about EMERGE?*
Other*
Have you been previously enrolled in a personal development program? What was your experience?

How would you rate your satisfaction with your life overall?

	1	2	3	4	5

1 is Unsatisfied , 5 is Completely Satisfied

What made you apply? Share your reasons and desired end results.
Are you prepared to commit 60-90 minutes to the weekly calls?

YesNo
Please choose your preferred payment option.

Full payment of $5972 installments of $327
Preferred Payment Method

Payment link (debit/credit card)FCIB Bank TransferZelle
Choose the session times that work best for you (select all that apply)

Mondays @6:30pm ESTTuesdays @6:30pm ESTSaturdays @9:30am EST
By signing below, I understand that this program is not a replacement for therapy or counseling. I agree to follow the program and to relinquish any legal claim against Holy Spirit Heal Her, Heal Her Academy, EMERGE, Shakeisha Johnson or any other subsidiaries associated with the aforementioned parties.

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Application Form