REDIRECT YOUR LIFE Experience

Total cost of course $495.00 this requires a $100.00 Deposit. (Balance due before the weekend.)

Student Name *

Date of Birth *

Phone Number *

Address *

City *

State *

Zip Code *

Course Location *

Course Date *

Enrolled By

PLEASE LIST: NAME - AGE - OCCUPATION - PERSONALITY TRAIT - YEAR DIED (if applicable) for:

Yourself *

Your Mother *

Your Father *

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Sibling 5

Sibling 6

First Child

Second Child

Third Child

Fourth Child

Fifth Child

Sixth Child

Early Recollections
An early recollection is a memory of a SPECIFIC INCIDENT that occurred when you were a child, particularly before age 8. Write down the first two memorable childhood events that rise up in your heart. Give your approximate age and note how you felt at the time. It doesn’t matter if the experiences you recall are positive or negative.

Example of an early recollection: Age 4-5 One day my parents brought home a new baby. I felt lonely and left out.

Notice that the above recollection describes a specific incident. It is not a generalized report.

The following is NOT an early recollection: When I was a kid I always used to ride my tricycle and fight with my brother.An early recollection is a memory of a SPECIFIC INCIDENT that occurred when you were a child, particularly before age 8.

Write down the first two memorable childhood events that riseup in your heart. Give your approximate age and note how you felt at the time. It doesn’t matter if the experiences you recall are positive or negative.

Example of an early recollection:Age 4-5 One day my parents brought home a new baby.I felt lonely and left out.

Notice that the above recollection describes a specific incident. It is not a generalized report.

The following is NOT an early recollection:When I was a kid I always used to ride my tricycle and fight with my brother.

Early Recollection 1 Age & Incident *

I felt *

Early Recollection 2 Age & Incident *

I felt *

Is there anything else that you would like to share that would better enable us to help you accomplish your goals?

List the names of those you know who have completed The REDIRECT YOUR LIFE Experience.

Additional Background Information

Employed By

Describe Your Responsibilities

How Are You Valuable To Your Company

Marital Status * Single Married Divorced Widowed

Describe Your Relationship

Do you have children? * Yes no

Describe Your Relationship With Them

Have You Ever Had Counseling? * Yes no

Is there anything that would have made your results more positive?

Other personal growth courses you have attended

Major physical illness or injury and the year

Goals *

How would you like for your life to be different as a result of completing The REDIRECT YOUR LIFE Experience?Be very specific about the results you desire to produce in these areas.

Career *

Family *

Friendships *

Intimate Relationships *

Yourself *

Tuition: Total cost of course $495.00 this requires a $100 Deposit. (Balance due before the weekend.)

Payment Method * Check Credit Card

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Credit Card Number

Expiration Date

CVV Number

Billing Address *

I am aware that breaking the agreement would greatly minimize the value I would gain from the course, and therefore, I will be responsible for overcoming any circumstances which would prevent me from keeping this agreement. I agree to attend, in their entirety, all sessions of the course. I agree to be on time for each session. I agree to return the Student Information Sheet and this signed Enrollment Agreement Form within 5 days. I agree not to take any non-prescription drugs or alcohol within 24 hours of any session. As a participant of this course, I agree to respect the confidentiality of all participants and their remarks. Informed Consent Agreement I understand that this course is educational and NOT psychotherapy or a substitute for psychotherapy.

I have read and understand this entire agreement and agree to these terms and conditions above. *