Application for The 12 Doors:

A 3-Month Immersion to Return to Your Energy, Your Rhythm, and Your Self

The 12 Doors is a deep 1-on-1 healing container for mindful women navigating big transitions, coping with chronic stress or illness, and/or desiring a foundational shift in their lives. Limited spots are available.

Please answer the following questions thoughtfully. This program will have the most impact on women who are resourced in other areas of their lives and committed to giving to themselves. If it's not a good fit, other resources and programs may be recommended instead.

First name

Last name

Email

Phone

How did you hear about us?

What are your top three challenges or complaints?

What does your current wellness and self-care routine consist of?

How many hours per week do you typically spend on the wellness activities above?

Are you actively working with a therapist or other mental health practitioner?

Yes

No

Not currently, but I have access to one I already know and trust

What other in-depth healing programs, spiritual containers, or wellness trainings have you done, if any?

Do you have any religious beliefs or observances you'd like me to be aware of? If so, please describe.

When you're feeling overwhelmed and burnt out, what do you typically do to come back to equilibrium?

What would success in this program look like for you?

What's important to you when working with a healing practitioner?

Is there anything else you'd like to share with me or that you think I should be aware of?

I acknowledge that this healing program is not a substitute for medical evaluation or treatment nor mental health services.