Mentorship Application

Name *

First

Last

Email *

Main Phone *

Alternate Phone

Are you hoping to work together in-person in San Luis Obispo or via video-confrencing from anywhere in the world? *

In-Person in San Luis Obispo, California USA
Remotely via Video Conferencing
A mixture of both

When do you hope to start our work together? * *//

How did you hear of me? *

Qualifying Scholarships?

Please read about available discounts and scholarships here.

**Why would you like to receive this scholarship? *

**What do you hope to gain from our work together? *

**How will you take the benefits of your experience out into the world to help others? *

Please tell me more about your current Social Justice Activism *

Please provide a brief statement of your financial need. *

Big Vision: *

If this one-on-one Intuitive Healing & Mentorship Program is everything you hope it will be, how do you imagine you, your life, your relationships and/or your work will be different on the other side of our time together? How will you know how effective this has been?

Personal Goals: *

What goals do you have for your work on yourself? What is it that you really want to be and do? What are your aspirations? What do you wish you could be great at doing? Where do you want to see yourself in the next six months (Please be specific.)

Pro-Active Action: *

How much energy are you willing to put into that? What are you willing to do in the next 30 days to move you towards the direction of your dreams? What small steps can you take today to get you closer to your vision? What will you do different tomorrow to meet those challenges?

Existing Resources: *

What are you doing really well that is helping you get there? What skills, capacities, relationships, beliefs or inner tools do you already utilize to give you support, grounding, centering, release or inspiration?

Barriers for Success: *

What is holding you back? What are you not doing well that is preventing you from getting there? What are the biggest challenges, self-defeating behaviors or roadblocks you have in your life right now? What could you do less of?

Resource Development: *

In order to really live your vision & achieve your goals, what skills, or resources do you think you need to build? What might you need to heal?

Sabotage: *

What (if anything) do you find challenging (or imagine might be challenging) about showing up fully for one-on-one personal work with a supportive mentor or ally? How might you sabotage your own growth or our professional relationship?

Mentorship Relationship: *

How can I help? What do you most desire / expect from this mentorship relationship? What can I do to help you succeed?

Energy, Motivation & Passion: *

Where do you get your energy? What motivates and turns you on in your life right now? What are you passionate about?

Stress Release: *

What do you find works for you to release stress?

Pleasure: *

How do you like to enjoy yourself? What do you enjoy doing?

Challenging Relationships: *

Is there anyone in your life who regularly puts you down, criticizes you, or whom you feel you have to tread carefully around?

Values: *

What are your values or the things in life that you see as standards for your behavior or what you judge as most important in life? If you are unsure of this we will explore this in-depth as part of our mentorship process.

What am I NOT asking you that you really want me to ask? * *

Is there anything else you'd like me to know about you?

Any questions or requests you have for me? *

Please note: The State of California does not license practitioners of complementary healing arts such as Yoga Therapy, Reiki, Intuitive Healing or Counseling/Mentorship. *

Acknowledgment of non-licensure

Captcha *

What is the second letter of the alphabet?

Intuitive Healing & Mentorship Application

I look forward to connecting with you shortly!

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