Health Form | Hearts and Minds Development

First name

Birthday

Day

Month

Year

Address

Phone

Social Handle

Dietary Requirements (for our graduation celebration)

How did you hear about Hearts and Minds Development?

What do you hope to achieve or learn?

What courses, certifications, or personal development programs have you completed?

Where do you dream of being 12 months from now?

What’s stopping you from getting there?

Do you have any mental health challenges, diagnoses or unresolved trauma that you feel I should know about?

Is there anything else you’d like me to know?

Agreement statement:

"I understand that Immersion Days are educational & INTERACTIVE."

"I cannot coach on things I do not embody myself. Therefore, I’m willing to be an active participant and come in with an open mind, open heart and epic attitude."