Page 1 of 1

Application Form with Imogen

For making sure we are the right fit to start improving your cognitive capacity

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

1. Name

2. Email

3. Instagram handle or Preferred contact

4. Package Preference

5. If you selected Group Mentorship - what is your Tier Preference?

A
B
C

6. Which statement feels most true for you?

A
B
C
D

7. How would you describe your current role?

Eg. Occupational therapist in Community, Team Leader for Allied Health, Physiotherapist in the Hospital, Sole Trader

8. What are you hoping this work will support you with most right now?

eg. I want to be more present with my family, I can't get work out of my mind, I really want to support my team

9. What would you say is taking up most of your cognitive load / head space at the moment?

eg. Complexities of funding bodies, all the admin tasks, demanding clients, case notes at 10pm

10. What are you hoping to achieve from our time together?

11. How much time could you realistically dedicate each week to applying what you learn?

12. What time zone are you in?

13. Anything else I should know?

14. Payment Preferences

A
B
C

15. Have you engaged in any of Imogen's other teachings?