Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Do you use Whats App or Signal for voice memos? *

Whats App

Signal

Neither

If not, are you willing to explore utilizing this form of communication between sessions if we work together?

Yes

No

Let's talk about it

What type of experience are you interested in?

Drop-In

3 Month Evoluton

6 Month Evolution

Mentorship

Are you currently moving with any physical injuries? *

Yes

No

Do you have any mental or medical conditions that may be aggravated due to physical work or psychological stress? *

Yes

No

I acknowledge the following DISCLAIMER: I understand that Samantha is not a doctor, psychotherapist, psychologist, therapist or other licensed or registered professional. Samantha will not act as a therapist providing psychoanalysis, psychological counseling or behavioral therapy. I understand that Samantha will not attempt to diagnose, treat or cure any disease, condition or other physical or mental ailment. *

Yes

Please confirm that you have completely and honestly answered the health questions in the application. *

Yes

In the case of an emergency, I acknowledge that I am responsible for my own health care costs. *

Yes

No

I acknowledge that all of the information I have provided is true *

Yes