PRIVATE 1:1 COACHING + REBIRTH CEREMONY APPLICATION

*First Name

*Last Name

*Age

*Email

*Phone Number (If outside of the US, include your phone number + WhatsApp number)

WhatsApp Number

*How did you find out about PLAY Alchemy? *How did you find out about PLAY Alchemy? Instagram Facebook Twitter TikTok Referral Other

*If you answered REFERRAL, please specify

*If you answered OTHER, please specify

*Please enter the link to your Instagram account

*What about the PLAY Alchemy Private 1:1 Coaching + Rebirth Ceremony program interests you? Why do you think it will be helpful to you?

*What does the word REBIRTH mean to you?

*What do you anticipate experiencing in a rebirthing ceremony?

*Why do you think it will be helpful to you?

*What's your definition of play (not the dictionary definition)? How important is play to you? By your own definition, how often do you play?

*On a scale of 1 to 5, 1 least and 5 most important, how much do you currently make your own joy, laughter, inner peace, and fulfillment a priority?

*Describe your current life. What's working for you? What's not working for you?

*What kind of shifts do you desire to bring forth in your life?

*What are you willing to do to make those shifts your new reality?

*How much have you invested on coaching, wellness, and/or self-improvement this past year? (Answer should reflect the total for all services you paid for in the last year) *How much have you invested on coaching, wellness, and/or self-improvement this past year? (Answer should reflect the total for all services you paid for in the last year) Under $10,000 $10,000-$50,000 $50,000-$100,000 $100,000+ $500,000+

*In detail, describe the challenges that are affecting you - particularly the cycles you find yourself in that have been difficult for you to break. How long have you had these challenges? How do they affect your everyday life? Be as descriptive as you can. Include any awareness (if any) of childhood experiences or trauma that you are comfortable expressing.

*What other methods of relief (if any) have you tried to help you overcome these challenges? (i.e. other coaching programs, healing modalities, reiki, meditation, breath work, yoga, healing centers, etc.)

*Are you currently seeing a Psychotherapist or Psychologist? Which kind and for how long?

Are you taking any prescription medications? Are you taking any prescription medications? Yes NO

*If you answered Yes, please specify

In detail, describe the current state of your most intimate relationship. (i.e: your partner/spouse, family member, friend, religious/spiritual leader, etc.)

In detail, describe your support system. Who are the 5 people that influence you the most? Do you feel safe in these relationships? Are you able to be your whole self around them? Are you able to completely fall apart and call upon them for support when you need help? Are you able to celebrate fully with them when amazing things occur?

Where do you want to be, and how do you want to feel in 4 months AND in 1 year from now?

Are you committed to investing $4000-$5000 USD per month for a minimum of 4 months, knowing that the returns of inner peace, fulfillment, and growth in all areas of your life are priceless? Are you committed to investing $4000-$5000 USD per month for a minimum of 4 months, knowing that the returns of inner peace, fulfillment, and growth in all areas of your life are priceless? YES! I am 100% committed and this is a TOP priority for me. I will do whatever it takes to overcome my challenges and transform my life! No. I am not ready - just curious and browsing around. What are your lower payment options?

*A limited number of new clients are accepted into the PLAY Alchemy Rebirth program. If your application is accepted, are you committed to completing the remainder of the application process? *A limited number of new clients are accepted into the PLAY Alchemy Rebirth program. If your application is accepted, are you committed to completing the remainder of the application process? Yes No