Application to work with me — Jacquie Eva Rose

Name

First Name

Last Name

Phone

(###)

###

####

What form of service are you interested in?

1-1

Group experiences

How did you hear about me?

Internet search, advertisement, friend? - please specify who and where exactly

Where are you now in your life that you are seeking support with?

What drew you to me specifically to help you with that?

Where do you want to be?

Do you have a practice to still your mind? If so, please explain

Have you worked with archetypal or alchemical energy before? If so, in what context?

Have you been in therapy in the past or presently? If so, when and in what form? (That is: What work are you presently doing or what have you done to heal the emotional woundings of your passage through life?) Please be specific as to the type and length of work.

Are you in recovery from drugs, alcohol, or any other addiction? If yes, for how long and what kind of recovery have you engaged in?

In the past five years (or currently) have you been prescribed any psychiatric medications? If so, please list which one(s) and for what they were prescribed.

Place your hand on your heart, turn to the wise inner self and ask, are you ready for your next step of growth and change?

Is there anything else that you feel is important to share?

Hello beloved sister!

I’m so pleased to hear that you would like to work with me either in a 1-1 capacity or attend a group experience.

Please answer the following questions and submit your application. Once submitted, please allow 48 hours for a response.

With love
Jacquie