Consultant Intake Form

A copy of your submission will be sent by return mail for your reference.
After reviewing your submission, we will be in touch. Thank you!

Name*
First Last
Age*
Gender*
- Male
- Female
- I prefer not to identify
Email*
Skype
Phone
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Education*
Include college degrees, certifications, professional courses, and dates received for each.
Work Experience*
Have you conducted/participated in any holistic practices? e.g. Rieki, re-birthing, etc. used an naturopath/herbalist? If so, which practice(s) and for what length of time? What was the result of your participation?
Why do you seek certification?*
For what reason(s) do you want to help people with their life situations/problems?
Social Service*
If you have been helping people with their life situations/problems – for how long? And in what capacity?
More About You*
Share more about yourself. What makes you who you are?
Your Adverse Experiences*
Have you experienced an adverse or traumatic situation/event in your life? If so, share highlights. What type of therapy/healing have you used to process the situation/event?
Integrating My.EM*
How you do you intend to integrate the MyE.M. process into to your current practice?
Commitment*
Are you willing to commit to the learning experience of MyE.M. for 6 months? Classes will take place once every two weeks.
- Yes
- No
- Not Sure
Thank you .

Beverley Searle
Beverley@myenvisionedmind.com
GDPR*
- I consent to my submitted data being collected and stored for use by My.EM in compliance with our policies aligned with the GDPR and as laid out in the Privacy Policy.
Phone
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