BrainSpotting Program Application

1
Hi there! Tell me your name.* This field is required.
First Name
Last Name
2
Email* This field is required.What's the best email to reach you at directly?
example@example.com
3
Phone Number* This field is required.What number shall I call you at for our session?
Area Code
Phone Number
4
AddressIf we decide to work together, where should I send your welcome kit?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Imagine that we’re talking one year from now about the progress you’ve made to live as the Intuitive Leader you are meant to be as a result of our work together... what changes are we celebrating?* This field is required.
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Ok
Ok
6
What factors or obstacles OUTSIDE of you could prevent you from accomplishing the GOALS you just shared?* This field is required.
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Ok
7
What factors or obstacles WITHIN you could prevent you from accomplishing the GOALS you just shared?* This field is required.Example: I’m terrified! I get easily overwhelmed. I don’t feel ready.
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Ok
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How can I support you in overcoming these external and internal obstacles?* This field is required.
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9
Tell me how you want to create CHANGE in your life and how those changes will impact you as well as the people around you.* This field is required.
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10
Are you currently taking the steps to address the CHANGE you want to make?* This field is required.
Yes
Not Yet
Sort of...
11
Are you serious about making the CHANGE you want to make?* This field is required.
Yes! 100%
I'm Not Sure
12
If there's a fit, what are the reasons you will be committed to working harder than anyone to accomplish your CHANGE and making the impact you want to make?* This field is required.
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13
Think for a minute... Tell me about what’s working well in your business and life.* This field is required.
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Ok
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What’s not working well?* This field is required.
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Are you looking for a proven method and coach to help you find your freedom, clear your past and expand into your future so you know you are seen, heard and respected; recognize your blind spots to own every situation (good, bad, ugly); and break the cycle of feeling too overwhelmed, underappreciated, or unsatisfied for good this year?* This field is required.
Yes. I invest in myself often and get a massive return on my investments
Maybe. I haven’t played “all in” before and I’m nervous but something has to change!
No. I'm not ready to invest but please send me all the free information on how I can make the most of my intuitive leadership qualities.
16
OPTIONAL: Share any links supporting your application. This can include links to your LinkedIn profile, resume, website or blog, your social media platforms, letters of recommendation or testimonials, or anything else you think will help me in making my decision.
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You did it! Just click “submit” and your application form is complete.

After you do, either my assistant or I will confirm your Breakthrough Insight Session -- on Zoom. That’s where we’ll answer any questions you have, experience BrainSpotting and explore whether or not my signature programs provide a solution for you.

You will be notified within 3 business days about whether or not your application is accepted.

If your application is incomplete or not accepted, your session will be postponed or canceled.

I’m so excited to receive your application!

Thank you.
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