Introduction

Please enable JavaScript in your browser to complete this form.

Name

First

Middle

Last

City, State & Zip

We don’t need your street address, just your city, state and zip code.

Phone Number with Area Code

What is your Belief System?

This is private not shared in workshop, unless you bring it up. It’s only so I can respect your beliefs.

Why do you want to change?

This is private not shared in workshop. Your why must be bigger than the concern for lasting change to happen.

Introduce yourself

Parts of this may be shared in workshop, (Put in parenthesis if you want it to be kept private) Are you single or married, who is your spouse, do you have any kids, where do you work, do you enjoy your work, what are your hobbies, what do you like best, what do you least like, and anything you want to share.