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Name

Date of Birth

Email address

Phone Number

Occupation/Business Title

What made you interested in this intensive experience?

What’s currently keeping you up at night—mentally or emotionally?

What’s something you’ve tried (therapy, coaching, retreats, etc.) that didn’t work as well as you hoped?

What would a meaningful shift look like for you after this intensive?

Have you been diagnosed with any mental health conditions (past or present)? (Being diagnosed does not prohibit you from an intensive) Check all that apply

Anxiety

Depression

Trauma/PTSD

ADHD

Autism

Substance Dependence

Eating Disorder

Other

If you checked other, please explain.

Are you currently working with any of the following Check all that apply

Therapist

Psychiatrist

Mindset/Life Coach

Business Coach

Have you ever experienced hallucinations, delusions, or significant breaks from reality?

Yes No

Have you ever been diagnosed with a personality disorder (e.g., borderline, narcissistic, etc.) or experienced lifelong significant interpersonal instability in relationships?

Yes No Not formally diagnosed, but I relate to some traits

Have you ever been hospitalized for psychiatric reasons?

Yes No

If yes, please describe circumstances, including year.

Are you currently struggling with any of the following? Check all that apply

Suicidal thoughts or behaviors

Self Harm

Substance misuse or addiction

Disordered eating

None of the above

This intensive involves confronting discomfort and engaging deeply in emotional and somatic work. Are you currently in a place where you feel resourced and supported enough to do this?

Yes No I'm not sure

Do you have any physical health concerns that might affect your ability to participate in somatic work (e.g., breathwork, grounding, light movement)?

Yes No

If yes, please explain.

Is there anything else you'd like me to know as I review your application?

I understand that this intensive is not a replacement for ongoing therapy or psychiatric care. By submitting this application, I acknowledge that I am applying for a therapeutic experience designed to support psychological growth and nervous system regulation, and that final participation is based on professional discretion.

Once your application is reviewed, you may be invited to a brief consultation call to ensure a mutual fit. Please only apply if you are seriously considering participating and prepared for a $15,000 investment.

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