Form

Applied RePatterning™

Client Application
This is a structured application.

This work is stabilization-first.

Not all applicants will be accepted.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
CURRENT SITUATION: Describe your current situation in clear, concrete terms.
Where is instability most noticeable right now?

Mental (looping, confusion)Emotional (overwhelm, reactivity)Physical (fatigue, dysregulation)Behavioral (avoidance, inconsistency)
How long has this been occurring?
What have you already tried?
Can you follow simple instructions consistently over time?

YesInconsistentlyNo
Where does change primarily occur?

External circumstancesOther peopleInternal structure and behaviorNot sure
Are you prepared to apply structured work between sessions?

YesMaybeNo
Are you prepared to invest in the One on One 3 session container over 3 weeks if accepted?

YesNot yetUnsure
This work is direct.
It is structured.
It does not rely on interpretation or emotional processing alone.

You will be asked to observe, apply, and stabilize.
I understand this is structured work and requires active participation.*

I understand and agree.
*Applications are reviewed in order of submission.
If accepted, you will receive next steps.
Should be Empty:

Applied RePatterning™