Page 1 of 1

Online 1-on-1 Mentorship Session Application Form

This brief questionnaire helps me tune into where you're at and make sure this space is the absolute best fit for your journey right now.🤍

Name

Email address

Relationship Status & Intentions

Where are you currently in your journey?

Currently in a relationship I want to transform

Single and ready to call in deep love

It's complicated / transitions

What is currently calling you to this space?

What is the main loop, pattern, or dynamic you feel ready to step out of?

Have you done somatic, mindset, or inner work before?

Brand new

A little

Deeply familiar

What does a 'successful' session look like for your body and heart?

Which mentorship container feels like the right fit for you right now?

Single Mentorship Session ($50)

4-Session Mentorship Package ($170)

I'm open / would love to decide together based on what I need

Is there anything else you’d like me to know about your current life or relationship right now?

Section 3: Important Disclaimer & Alignment Checks

Mentorship & Mental Health Disclaimer: This mentorship container is a space for personal development, somatic integration, and mindset/polarity alignment. It is not psychological therapy, clinical counseling, or psychiatric treatment. If you are currently navigating active mental health conditions, severe clinical trauma, or crisis, please seek care from a licensed healthcare professional.

Agreement

I understand that this is a mentorship space, not psychological therapy.

I am ready to take radical responsibility for my own life, choices, and transformation.

I am ready to invest in this container ($50 for a single session / $170 for the 4-session package) if my application is approved.