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Getting to Know You:

Full Name
Which container are you applying for? (3, 6, or 12 months)
Include details about your family, such as kids' ages, partner, and household dynamics.
Share what attracted you to this program.

Current Struggles:

What do you find yourself repeating (emotionally, verbally, energetically) even though you don’t want to?

Emotional & Energetic Landscape:

Selected Value: 0
0 being calm and regulated vs 10 being completely overwhelmed and maxed out.

Coaching Rediness:

What has changed in your life that has made room for consistency, growth, and healing?
Please explain any previous experiences you've had in these areas.

Capacity & Commitment:

This includes weekly sessions and check-ins
Do you plan on telling family or friends? Why or why not?
Share anything else you'd like to about your story or intentions.