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Awakening Coaching Application

Congratulations on your decision to participate in the Awakening Coaching Training. We are excited to welcome you to the course.

Please take a few minutes to complete this simple application. After your application has been reviewed and accepted, you will be asked to pay your deposit for the course, or you may choose to pay the full balance at the same time. Once your deposit has been received, your place is reserved. Once your full balance has been received, you become eligible to receive affiliate commissions.

First, please tell us who you are and how we can stay in contact with you
First Name
Last Name
Gender
Male Female
Date of Birth
Age
Street Address
City
State
If you live outside the US: Postcode
Country
   
Your phone numbers:
Home Phone Country Code Area Code Phone
             
Work Phone Country Code Area Code Phone
             
Fax Country Code Area Code Phone
             
Cell phone Country Code Area Code Phone
             

Email Addresses
Email 1
Email 2
Occupation
   

Contact Information in case of emergency:
Contact Name
What is your relationship to this person?
Full Address
 Emergency Contact Phone Numbers
Home
Work
Fax
Cell
   
Emergency contact Email address
   

Now please tell us something about your background and reasons for taking this course. All information will be held in strict confidence.
How did you come to know about Arjuna’s writing and teachings?
   
Have you taken a weekend intensive with Arjuna?
Yes No
Date
Location
   
Have you taken any part of the Living Essence Training before?
Yes No
Date
Location
   
Have you attended an evening talk or Satsang with Arjuna?
Yes No
Date
Location
   
Please indicate which of the following books and audio and video products you have read, listened to or watched:
Leap Before You look Book The Last Laugh
Leap Before You Look CD How About Now
Awakening into Oneness Book Relaxing into Clear Seeing
Awakening into Oneness DVD Living Essence Audio Series
Let Yourself Go CD series Audio of talk or satsang
The Translucent Revolution Video or DVD of talk or satsang
   

Please briefly summarize your other experiences of spiritual development and exploration. Please include any and all teachers, methods trainings and results, both positive and negative.

 

Please briefly describe any spiritual awakening or other opening or peak experience that has been significant for you.

 

Please describe the major blocks or habits that most interfere with your being able to live your deepest awakening.

 

Please now describe what is your primary motivation for taking this course. Is it personal or professional or both? Do you intend to take all 3 levels? Do you intend to also continue on to assisting in three levels and to getting ordained as a minister?
   

Medical History

The following questions might seem to be personal and intrusive, but are simply intended to help everyone get the most out of the training, and for the training staff to best support you. Once again, everything you write here will be held in strictest confidence, and will never be shared with anyone else.

 
Do you currently have any health problems like diabetes, asthma, high blood pressure, epliepy or heart problems? Please explain

 

Are you currently under a doctors care taking any specific medications? If so, please describe the condition, the medication and any side effects

 

Are you currently taking any anti depressant or other psychiatric medication? Are you currently under the care of a psychiatrst or clinical psychologist?

note: this will not necessarily preclude you from taking this training, but we may need your psychiatrist’s or psychologist’s permission and endorsement.

 
Have you ever been admitted to a mental hospital? If so, please indicate the date and duration.

 

Are you currently using any recreational drugs, including marijuana, ecstacy, cocaine, amphetamines, heroin etc? Have you used any such drugs in the last year?

 

Do you smoke cigarettes? Do you drink alcohol? If so, please indicate how much and how often.
   
Are you pregnant?
Yes No
   
Do you have any communicable diseases? If so, please explain

   
Please type your name below, as a form of electronic signature
   
Please enter today’s date.  
 
   

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