The J.A.M. Effect™ Intake Form

The J.A.M. Effect™ Intake Form
Participant Information
Full Legal Name

First NameMiddle NameLast Name
Preferred Name
Pronouns
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City / Province
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to You
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Program Details
Which cohort are you registering for?
Payment Preference.

Other
I understand that the full investment for this program is $630. I also understand that the program fee remains the same regardless of attendance, and that missed sessions are non-refundable.
Have you participated in Slay Your Inner Critic or an earlier version of this work before?
Reflective Questions
What made you say yes to The J.A.M. Effect™ right now?
Where do you notice your inner critic showing up most?
What would it mean for you to leave this program with a different relationship to that voice?
Is there anything happening in your life right now that you'd like your facilitators to be aware of?
Group Readiness
How do you feel about sharing openly in a small group setting?

Other
Are you currently working with a therapist, counsellor, or coach?

Other
Is there anything that would make it hard for you to attend all 7 sessions?
Agreements & Consent
Agreement: Group confidentiality

Other
Agreement: Not therapy or crisis support

Other
Agreement: Camera-on and punctuality

Other
Optional: Marketing consent
Participant signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Wrap-Up
How did you hear about The J.A.M. Effect™?
Anything else you'd like us to know before we begin?
Should be Empty:

The J.A.M. Effect™ Intake Form

Participant Information

Emergency Contact

Program Details

Reflective Questions

Group Readiness

Agreements & Consent

Wrap-Up