Dream Life Application

1. How did you hear about this program?
2. What interests you about this program?
3.What makes you feel now is the right time to participate in this program?
4 .Do you have any issues or conditions that may prevent you from fully participating in this program?
5. Are you under the care of a psychiatrist or taking any medications for mental conditions?

Terms & Conditions
We only accept 10-12 applicants into The Dream Life Program. A commitment of payment is due to reserve your spot. We accept Visa, Mastercard, and American Express, Discover and PayPal. It is important to be at every session. If you need to miss a session you will receive a copy of the material covered. Private makeup sessions are optional and are available at a discounted rate of $100 per hour.

Signed (by clicking the box on the right, I agree)
Name:
Address:
City:
State:
Zip:
Date:
Phone:
Email:
Comments:
	*Upon acceptance of your application payment procedure will be emailed to you.