Single1:1_Mentorship

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 (I can be flexible)

Why are you interested in mentoring at this time? Please describe your main concerns in as much detail as possible.*

In an ideal situation, how do you feel this mentorship could help you at this time?

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 have you tried in the past that hasn’t worked for you?

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

YesNo

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

YesNo

What following goals do you connect with?*

If you answered "other" to the above question, please elaborate below. What primary goal do you have for the mentoring session?

Are you able to invest in this mentorship session at this time? (Single sessions are $200US)*

YesNoNot currently, but within 3-6 months

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

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 75 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.) 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. Treatment of ligitimate mental health conditions is beyond the scope of this mentorship.

4.) CONFIDENTIALITY

For the duration of the mentorship, 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 publicly share recordings of sessions in either audio, photo, or video format and am aware of the legal consequences of doing so.

5.) 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