Anilah Mentorship Form / 2 Month Container

The INNER ALCHEMY 2 Month Container Includes:

4 x 90 minute sessions (2 per month)

Bi-monthly email or telegram check in for questions.

Custom reflections summary via pdf upon completing the container.

Total Price: $1700US (payment plans available)

Option to continue mentorship on a month to month basis.

*Note: Custom packages are also available on request.

Full Name*

First NameLast Name

Email*

example@example.com

Gender or preferred pronoun*

Age*

years

What city/timezone do you live in?*

What days of the week are you available for mentoring? *

Based on your available days, please choose a time of day that you are most available for mentoring:*

Morning (7am - 11am)Afternoon (11am - 4pm)Evening (5pm - 8pm)Any time of day

Have you seen a therapist or coach in the past? If so, please describe your experience - what worked for you, what didn't? *

Are you currently seeing a therapist or coach?*

YesNo

In the past 2 years, have you been treated by a therapist or other mental health professional for issues such as depression, anxiety, trauma, or other mental health concerns.

YesNo

How many hours a day can you commit to activities related to the mentoring sessions? (Exercises, reading, meditations, and other processes)*

30 minutes1-2 hours3-4 hours

Please briefly introduce yourself (Include what you do for work, your social/family life, primary hobbies or interests, etc...):

Why are you interested in the mentorship at this time? Please describe your main goals and what you would most like to shift as a result of working together. *

Do you currently find yourself on a threshold in your life?

YesNoUnsure

What are the main blocks or challenges that you are currently experiencing at this time which are relevant to this mentorship?*

What methods have you tried in the past that haven't worked for you?*

Do you have experience with somatic based practices and/or nervous system regulation?*

YesNo

Do you have a daily spiritual, devotional, or inner work practice?*

YesNo

Which inner work practices are you currently engaged in?*

Please rate your readiness for change and transformation. (For example, 10 would be "I am completely committed and devoted to this mentorship, and am ready to be engaged in a deeply transformative process.")*

What do you hope to achieve through this mentorship? In an ideal situation, describe what your life would look like in one year if your main concerns were addressed and resolved. *

What following goals do you connect with?*

Name the intention and commitment you have for yourself by stepping into this mentorship container. *

Are you able to invest in this mentorship container at this time? (The total cost is: $1700 USD(Or payment plan of 2x $900 USD).*

YesNoNot currently, but within 3-6 months

Are you requiring financial assistance at this time? This work exists in the spirit of mutual respect and sustainability. If you need financial support to access this container, a limited number of equity-based spaces are available. Please discern your level of need with care.

YesNo

Is there anything else that you would like to add that you feel is relevant? Please elaborate below.

PLEASE READ:

1.) CANCELLATIONS

Cancellations should be made at least 48 hours in advance of a scheduled session. Sessions cancelled less than 48 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS TO SESSIONS

Each session shall be a maximum of 90 minutes in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) REFUNDS

Refunds of pre-paid mentorship fees will only be considered in the event of serious illness or other emergencies.

4.) DISCLAIMER

Mentorships do not fall under the category of therapy and are not a replacement for legitimate mental health treatment. The client will be reffered to a specialist or clinical therapist if a need presents itself. As a mentee, I understand that treatment of ligitimate mental health conditions is beyond the scope of this mentorship.

5.) CONFIDENTIALITY

For the duration of this mentorship container, each party shall treat the other party's Confidential Information as confidential and safeguard it accordingly. As a mentee, I agree to keep confidential and not disclose to any third party any confidential information received from the other party during the term of this agreement. I will not share recordings of sessions in either audio, photo, or video format and am aware of the legal consequences of doing so.

6.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I understand that all the information given will be kept confidential.

I AGREE TO THE ABOVE TERMS & CONDITIONS!

YesNo

Mentorship Application