Generosity Fund Interest Form

Thank you so much for taking this time to help me help you! Please fill out this interest form to be put on the generosity fund recipient list to receive services gifted at no cost to you.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Preferred Method of Contact (e-mail, text, phone call, etc.)

Location

Date of Birth

In a few sentences, describe your experience with this current life transition you find yourself in: (Recent past, or present, near future or any combination of the three, whatever is most relevant)

Do you have any particular mobility, transportation needs or other specific requests?

Is there anything else you would like me to know?

Disclosure Statement

All information shared in this form & during your session(s) will be kept confidential. I am not a professional or certified healthcare provider of any kind, I am an ally & educator. Any & all recommendations given are not prescriptions or guarantees. I will not diagnose or treat. My work is to help you connect with your body wisdom, inspiration, & information you need to thrive. Quarterly, and as funds become available, I will select individuals for recipients of the generosity fund. Please check the box below to signify you understand the above statement, & release me from liability Thank you & Blessings on your Journey!

I agree