Beneath the Burnout™

12-Week Signature Group Coaching Application

First Name *

Last Name *

Email *

SECTION I: Intent & Readiness

Why are you seeking support at this stage in your life and leadership? *

What are you currently experiencing that you would describe as burnout, exhaustion, or depletion? *

How is burnout currently impacting your leadership, relationships, decision-making, or well-being? *

What have you already tried to address your burnout? *

SECTION II: Fit & Expectations

What are you hoping to gain from Beneath the Burnout™ specifically? *

This program requires weekly participation, reflection, and implementation. On a scale of 1–10, how committed are you to doing deeper self-work over 12 weeks? *

What does sustainable ambition look like for you? *

SECTION III: Scope & Appropriateness Screening

Beneath the Burnout™ is a trauma-informed coaching experience. It is not therapy, crisis care, or a substitute for mental health treatment.

Are you currently experiencing any of the following? (Select all that apply) *

Active suicidal thoughts or self-harm behaviors

Recent psychiatric hospitalization (within the last 6 months)

Untreated substance dependence

Severe depression impairing daily functioning

Active domestic violence or unsafe living environment

Ongoing legal or custody crisis

None of the above

(If any are selected, please briefly explain.)

Are you currently under the care of a licensed mental health professional? *

Yes, and stable

Yes, but in crisis

No, but I believe I may need therapy

No, and I am emotionally stable

(If in crisis or unsure, please explain.)

SECTION IV: Group Integrity & Responsibility

This is a high-accountability group environment. Are you willing to: *

Respect confidentiality

Participate actively

Receive feedback without defensiveness

Be coachable

Take responsibility for implementation

Seek therapy outside this program if deeper clinical care becomes necessary

Legal Disclaimer

Beneath the Burnout™ is a coaching and personal development program. It is not psychotherapy, medical treatment, or crisis intervention. Participation does not establish a therapist-client relationship. If you are in crisis, please contact 988 or your local emergency services.