Divinely ME Program Application
Please take a minute to fill in the following information if you are interested in applying to any of our Divinely ME programs for Peer mentorship or Life coaching. If the program you desire if currently full, you will be placed on a waiting list.
First Name
Last Name
Address
Email
Phone Number
Which program are you applying for?
Select a program:
Kismet Intercessions Program $75.00 monthly
G.L.O.W Motivational Program $100.00 monthly
Spiritual Nirvana Program $125.00 monthly
Guardian Angels Program (G.A.P) $125.00 monthly
Spiritual (G.A.P) Program $150.00 monthly
If you are applying to one of our family programs, how many clients are between the ages of 7-65 years old?
Select a household size
Parent plus 1-3 children
Parent plus 4-6 children
Parent plus 7-10 children
If you are applying to one of our family programs, what are some of the challenges your children are experiencing?
Behavioral (anger, withdrawn, emotional, outburst, etc.)
My child has a IEP or ARD plan with the school.
My child struggles with maintaining good grades.
My child is an At-Risk youth due to experiencing past trauma.
My child is struggling with Separation Anxiety from a parental figure or support system.
Have your ever worked with a Peer Specialist or Life Coach?
Yes
No
What are 3 changes you would like to make in your life over the next 90 days?
Currently, what are the most challenging obstacle(s) you are wanting mentorship to overcome in your life?
In order to successfully achieve your goals, please define what success look like to you?
What previous steps have you already taken to achieve your goals? What has been the result so far?
I agree to the terms & conditions
Your Signature
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