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i AM A THERAPIST, BUT i AM NOT YOUR THERAPIST. UNLOCK YOUR INNER GENIUS IS A COACHING CONTAINER. FILLING OUT THIS FORM ALLOWS FOR OUR HEALING RELATIONSHIP TO BE ETHICAL AND SUSTAIN INTEGRITY. EVERYTHING YOU SHARE WILL BE KEPT CONFIDENTIAL, AND YOU ARE NOT REQUIRED TO SHARE MORE THAN YOU ARE COMFORTABLE WITH.

First Name *

Last Name *

Email (one you check often, as this is how I'll let you know if you've been accepted) *

Have you tried anything to address rejection sensitive dysphoria or fear of rejection, and if so, please describe what that was and your experience *

How do you usually cope with rejection sensitivity? (No judgment here -- meltdowns, shutdowns, shame spirals, outbursts are held with love, radical acceptance, and curiousity. <3) *

How does rejection sensitive dysphoria or fear of rejection show up for you? How does it impact your life? *

What have you struggled with most, regarding rejection sensitive dysphoria or fear of rejection? What has been your biggest obstacle in handling rejection? What part do you get stuck on? *

When you have been working on personal development in the past, and growing and transforming into a different version of you, what has worked for you, and conversely, what HASN'T worked for you? *

If I were to send you a message right now saying you were accepted, would there be anything holding you back? If yes, what is it? *

This is not therapy, it is coaching. Are there any medical or cognitive issues you have (ie., extreme dissociation, unintegrated complex trauma, TBIs, etc) that could challenge care? If there are, could you elaborate and let me know if it's something you believe you can work with? *

Do you have a history of complex trauma? If so, where are you in your journey of healing? You do not have to divulge any information about your trauma here. You could express it in terms of average levels of daily distress. For example 0/10 would mean that you experience very little or no trauma activation every day. 5/10 would mean you experience triggers strongly within your body but are able to use coping methods effectively. 10/10 would mean that you are in a raw state of triggers and trauma activation most days. *

Are you currently working with a therapist? *

Do you have supportive relationships in your life? (Family, friends, partners, etc, that are supportive?) *

Have you done any therapy or coaching programs before in the past, and if so, what were your experiences like? *

What is your Number One Goal for the 6 months of this program? *

Why are you interested in this program? *

I consent to receive communications and understand I can opt-out at anytime.

Once you click the "Submit Application" button below, you will be redirected to a confirmation page. I will review your application within 48 business hours. Our office hours are Monday - Friday, 9am-5pm Eastern time.

Thanks again, and I'll be in touch soon!

Once you click the "Submit Application" button below, you will be redirected to a confirmation page. I will review your application within 48 business hours. Our office hours are Monday - Friday, 9am-5pm Eastern time.Thanks again, and I'll be in touch soon!

Once you click the "Submit Application" button below, you will be redirected to a confirmation page. I will review your application within 48 business hours. Our office hours are Monday - Friday, 9am-5pm Eastern time.

Thanks again, and I'll be in touch soon!