Rebuild Cohort Application
Are you ready to come home to yourself?
The Rebuild Cohort is a 6-week trauma-informed coaching group for women who are ready to stop self-abandoning and begin rebuilding self-trust, boundaries, emotional regulation, identity, and embodied confidence. This group is for women who are stable enough for coaching, honest reflection, group participation, and personal accountability. It is not therapy, crisis support, or a substitute for mental health treatment. Please answer honestly. This application helps determine whether the cohort is the right fit for your current season.
Full Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Instagram Handle
What drew you to The Rebuild Cohort?
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What do you hope to feel, change, or reclaim through this experience?
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Which familiar patterns have you experienced? (Select all that apply)
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People-pleasing
Over-functioning
Difficulty setting boundaries
Feeling guilty choosing yourself
Emotional reactivity
Shutting down or disconnecting
Over-explaining
Low self-trust
Betrayal, breakup, or divorce recovery
Identity loss or rebuilding
Feeling stuck in survival mode
Disconnection from your body
Repeating unhealthy relationship patterns
Other
On a scale of 1–10, how ready do you feel to take honest responsibility for your healing and growth?
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Not ready
1
2
3
4
5
6
7
8
9
Completely ready
10
1 is Not ready, 10 is Completely ready
Are you currently in crisis, experiencing active suicidal thoughts, or needing immediate mental health stabilization?
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No
Yes
I'm not sure
Are you currently working with a therapist, coach, sponsor, mentor, or other support person?
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Yes
No
Not currently, but I have in the past
I am looking for support now
Is there anything else you would like to share to help determine if this group is a safe and aligned fit for you?
Are you able to attend most live calls? (Weekly 90-minute group video calls, reflection prompts, and integration practices for 6 weeks)
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Yes
No
I may need to miss one call
I'm not sure yet
What days/times generally work best for live calls? (Select all that apply)
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Weekday mornings
Weekday afternoons
Weekday evenings
Saturday morning
Sunday evening
Other
Are you prepared to make the $444 founding cohort investment if accepted? (Payment plan available)
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Yes, paid in full
Yes, with a payment plan
I'm interested but need to discuss options
Not at this time
Acknowledgment (please check all)
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I understand this is coaching, not therapy.
I understand this group is not for crisis stabilization.
I understand confidentiality and respectful participation are required.
I understand acceptance into the cohort is not guaranteed.
I understand payment is required to reserve my spot once accepted.
Electronic Signature
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Date
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-
Month
-
Day
Year
Date
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