PART 1: ABOUT YOU

First Name *

Last Name *

Phone *

Email *

City *

State *

Country *

Country

Age Range *

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Professional Context

Fragmentation Pattern *

Current Role *

Years in Field

Leadership Responsibilities

PART 2: YOUR JOURNEY

Please answer thoughtfully. These questions help us understand if we're the right fit for your journey right now.

Call to Coherence *

Current Transition *

Previous Inner Work *

PART 3: READINESS & COMMITMENT

Mental Health Context *

Why Now *

Capacity Checklist *

I can commit to attending 8 weekly live sessions (Wednesdays 7-9pm ET)

I can dedicate 30-60 minutes daily for practice and reflection

I have adequate emotional/psychological support for deep inner work

I'm not currently in acute mental health crisis

I have the financial capacity to invest in this program ($1,997)

I'm willing to be vulnerable and authentic in a group setting

I can receive feedback and challenge with openness

Support System *

PART 4: WHAT YOU'RE SEEKING

Service Leadership Vision *

Desired Outcomes *

PART 5: PRACTICAL CONSIDERATIONS

Referral Source *

Referral Details

Financial Option *

Full price

Payment plan

Schedule Availability *

Monday January12, 2026

Wednesday January14, 2026

PART 6: FINAL REFLECTION

Question for Us

We're almost done. These final questions invite your deepest truth.

Truth Carrying *

CERTIFICATION & AGREEMENT

By submitting this application, I certify that:

- All information provided is accurate and truthful

- I understand this is a transformational program, not therapy or mental health treatment

- I'm prepared for deep personal work that may surface challenging emotions

- I commit to showing up fully for myself and my cohort if accepted

- I understand acceptance is selective and not guaranteed

I agree to the above terms and certify all information is accurate *

Yes