Full Name
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Email
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Phone
Age Range
Under 30
30–39
40–49
50–59
60+
Current Role or Title
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Industry
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Annual Revenue (personal or business)
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Under $250k
$250k–$500k
$500k–$1M
$1M–$3M
$3M–$10M
$10M+
Energetic Readiness
Where are you right now in your journey of leadership, life, and legacy—and what called you to this container in this moment?
Which of these statements resonate with you?
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I’m tired of force-based leadership
I know there’s more power available, I just don’t know how to access it
I’ve mastered external success but feel misaligned inside
I’ve outgrown conventional leadership coaching and want something deeper
I’m ready to activate my erotic intelligence as a leadership source
I’ve done deep work before but something still feels missing
Other
If you answer OTHER above, give us a short explanation
Which modalities have you explored or worked with previously? (Select all that apply)
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Executive / Leadership Coaching
Psychotherapy / Counseling
Energy Work / Healing
Meditation / Mindfulness
Somatic / Embodiment Work
Breathwork
Plant Medicine / Psychedelics
Men's Group Work
Other
If you answer OTHER above, explain further.
Have you worked with energy, embodiment, or sexuality before?
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Yes, extensively
Yes, but not at this depth
No, but I’m open
No, and I’m unsure
What are you most seeking from this experience? (select up to 3)
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Energetic recalibration
Somatic embodiment
Magnetic presence
Soul-aligned decision-making
Nervous system leadership
Intimacy + relational depth
Sexual energy mastery
Business clarity + power
Do you have any current trauma-related, mental health, or spiritual conditions I should be aware of for safely working together?
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Yes
No
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If you answered YES above, give us more info.
Anything else I should know as I feel into your field?
Investment & Integrity
Why you, why now?
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Are you ready to invest $7,770 USD PIF (3-month initiation) or invest 6 monthly payments of $2,590 for a 6-month immersion?
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Yes, I’m ready to pay in full for a 3 month container
Yes, I’d prefer the payment plan for a 6 month container
Yes, I’m interested but would like to create a custom package
No, I’m not ready
If accepted, when would you like to begin?
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ASAP (as soon as possible)
Within the month
I need to schedule a consultation first
