BREAKDOWN, TERMS, AND INTAKE

Please review the terms below and fill out the intake form. This is required before our first session.

The mentorship consists of two sessions. One at the beginning of our time together and one a week later.
- During the first session, we will assess where you are currently at and where you would like to
  
  be. We will identify major roadblocks and establish a few main goals or habits to focus on.
- During the last session we will reflect, talk about our major takeaways, talk about major hold
  
  ups, and formulate a game plan for moving forward.

Priority email support M-F throughout the week is also available.

You are allowed to reschedule your session and check-in call one time if given a 24 hour notice. If you reschedule last minute or for a second time, that appointment will be missed. In case of an emergency, contact Randi as soon as possible.

If Randi has to reschedule for any reason, you will be given at least 24 hours notice. If a call or other support must be postponed because of maternity leave or another conflict, that will be discussed and decided upon before the program begins.

After the first session, refunds will not be issued. Please respectfully take any issue or dissatisfaction with the program to Randi so it can be resolved.

This mentorship is not meant to replace professional counseling or therapy, for Randi does not hold those certifications. This program serves as a complement to other therapies and personal efforts in becoming healthy and whole.

This mentorship takes a lot of vulnerability, awareness, and commitment from both of us. I promise to do my best to create a trusting and safe space for deep healing. Everything shared with me will remain confidential.

First Name*

Last Name*

Email*

What do you do most of the day? (what kind of work, stay at home, student, etc.)

When you get stressed out, where do you feel it in your body?

Do you currently have body pain? If so, where?

What are your life biggest stressors right now?

What triggers your stress?

What health issues and/conditions do you have going on?

Briefly list your medical history.

In a perfect world, what would your daily life look like?

What are the main obstacles keeping you from that ideal daily life? *

What kind of self care activities do you enjoy? How do you destress? (exercise, massage, yoga, journaling, etc.)

What are your main goals or desires to achieve within our time of working together?

Completing and returning this intake form creates a contract of trust. You understand and agree to the terms listed above and have filled out the questions honestly and to the best of your ability. Do you agree to fulfill my commitments and promises as previously indicated.

Yes

Thanks for submitting!

BREAKDOWN, TERMS, AND INTAKE

Mentoring