First Name *

Last Name

Phone *

Email *

Acknowledge that you are applying to see Mila for 2 x intensive in person sessions that will be filmed and used for social media and marketing purposes. *

I acknowledge my application

I am willing to travel into New Jersey for in person sessions *

Yes

Why do you want to do this? *

What are you hoping to release *

How long has this been going on *

What have you already tried *

Have you worked with Mila before *

Yes online

Yes in person

Anything you would not want filmed *

Availability notes *

Price acknowledged 222 per session *

I understand each session is $222, so $444 for both

Record a video of yourself, under five minutes, answering these five questions. It does not need to be polished, I just want to see and hear you.

1. What's your name, and where are you located?

2. Why do you want these sessions? What is going on that you want to work together?

3. How is it showing up in your body, your relationships and your life in general?

4. Why do you want to do this work in person with me?

5. How do you feel about being filmed, and sharing your experience to help other people?

Upload to dropbox, google drive or Youtube (unlisted) ensuring that the sharing settings are open so we can download it. Then drop the link to the video below

Your video link *

Release agreed *

I have read the recording release and I agree to all of it

Release is permanent *

I understand this permission is permanent and cannot be withdrawn

Signature full legal name *

Signed date *