Professional Referral

The ARC of Hope & Emergence

A Mindfulness-Based Journey From Awareness to Becoming
Thank you for providing a referral to The ARC of Hope & Emergence, a mindfulness-centered journey designed to nurture presence, resilience, and self-awareness.

Our programs offers a gentle and supportive space for individuals to explore mindfulness, emotional balance, and community connection.

Please complete the form below to share your referral. This form is non-clinical and focused on readiness, interest, and strengths. Once submitted, a member of our team will reach out to the referred member to schedule a brief welcome conversation.

Only use this form if you are a therapist, counselor, mentor, or community professional.
Referring Person's Information
Name*

First NameLast Name
Organization or Practice Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to the person being referred
Individual's Information
Name*

First NameLast Name
Age*
Which age group are you referring to?*

Emerging Lotus (age 18-26, women only)Lotus Rising (age 27+, co-ed)
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Reflection from Referral

This section invites you to share your reflections on why you feel this individual would benefit from The ARC of Hope & Emergence. There are no right or wrong answers please share from the heart.
What strengths or qualities are you aware of that would help them benefit from a mindfulness-based experience?*
How might mindfulness, reflection, and community support their current journey?*
Readiness for Mindfulness and Growth
Please check all that apply. These indicators simply help us understand where they may be on their journey.*

Shows curiosity about mindfulness or healing/holistic practicesWould benefit from a supportive, community-based groupDemonstrates openness to self-reflection and personal growthMay need structured, positive support for emotional balanceOther. Please discribe below
Other. Please share anything else you would like us to know.
I have discussed this referral with them and they have given permission for An Ounce of Kibou to contact them directly.*

YesNo
Should be Empty:

The ARC of Hope & Emergence

Referring Person's Information

Individual's Information

Reflection from Referral

Readiness for Mindfulness and Growth