Nervous System Application

Nervous System Reset Application Form

Founding Cohort Application - this application may take some time to complete in order to better understand what you are looking to gain in participating in this experience. Please complete all sections.
Full Name

First NameLast Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tell Me About You
What inspired you to apply for Nervous System Reset?
Which challenges are affecting you most right now?
Check all that apply

Other
On a scale of 1 - 5, how overwhelmed do you currently feel?

1

2

3

4

5

1 is Managing well, 5 is Completely Overwhelmed
Vision & Goals
If this program were successful, what would be different for you six weeks from now?
What are you hoping to gain from this experience?
Which of these outcomes are most important to you?
Healing & Wellness Experience
Have you participated in any of the following:
Commitment
Are you able to attend all six sessions?
Are you willing to engage in weekly reflection exercises between sessions?
Final Reflection
What is one thing you've been carrying that you're ready to release?
Is there anything else you'd like me to know before reviewing your application?
Agreement
By checking each box below, I acknowledge that I have read, understand, and agree to the following:
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Thank you

Thank you for applying to the Founding Cohort of Nervous System Reset.Applications will be personally reviewed. Qualified applicants may be invited to a brief 15-minute Fit Call to ensure the program is aligned with their goals and needs.
How did you hear about the Nervous System Reset?

Other
Disclaimer: Nervous System Reset is a wellness and psychoeducational experience and is not psychotherapy, mental health treatment, crisis intervention, or a substitute for medical or mental health care. Participation does not establish a therapist-client relationship with Transforming Hearts PLLC®. Individual mental health needs should be addressed through appropriate clinical services.

If you have any questions, please reach out to

mfrancis@transformingheartspllc.com

or call Mary Ann directly at 959-237-3382
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Nervous System Reset Application Form

Tell Me About You

Which challenges are affecting you most right now?

Vision & Goals

Healing & Wellness Experience

Commitment

Final Reflection

Agreement

Thank you