Jodie Goss
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Please read the
Terms & Conditions
before filling out this form
Application Form
1: Personal Details
Name
*
First
Last
[object Object]
DATE OF BIRTH
*
DD/MM/YYYY
GENDER
*
MALE
FEMALE
OTHER
RATHER NOT TO SPECIFY
OCCUPATION (Most Recent)
*
CELL NUMBER
*
Email
*
ADDRESS & ZIPCODE
*
2: Personal History
Thank you for sharing details of your medical history so that I can be prepared to give you necessary help and support.
How would you describe your illness/symptoms/issues/stuckness?
*
When did your symptoms/issues begin?
*
How has this affected your life?
*
To help me assess your suitability for the seminar, please tell me if you have any medical or mental health issues that you have not yet mentioned on this form
*
Do you know of someone who has used the Lightning Process to recover their health?
*
YES
NO
HOW DID YOU HEAR ABOUT JODIE AND THE LIGHTNING PROCESS?
*
How would you like to take the seminar?
*
In person
Via Zoom
Accessibility
Please tick if you require wheelchair access at the course venue.
*
Yes, I require wheelchair access.
Please tick if you would like to bring a support person with you. A support person is an individual who attends but does not complete the training course. There is no extra fee for your support person.
*
Yes, I would like to bring a support person with me.
3: Application Questions
Do you feel you can influence your health?
*
Yes
No
Maybe
Do you believe you can get better/resolve your issues?
*
Yes
No
Maybe
HOW DO YOU HOPE TO FEEL WHEN YOU HAVE RESOLVED YOUR ISSUES? E.G. MORE ENERGIZED, MORE FOCUSED ETC. (PLEASE LIST AT LEAST 4 THINGS)
*
When you resolve your issues, what would you love to do with your life? (PLEASE LIST AT LEAST 4 THINGS)
*
4: Confidentionality
Do you agree to maintain confidentiality with information shared by others during the training
*
Yes, I agree.
5: Terms & Conditions
If you are under 18 your parent or guardian will need to read and accept the Terms and Conditions on your behalf.
Agreement
*
I have read and accepted the Terms and Conditions
name (of participant, parent or guardian), signature and date
*
As a parent or guardian, what is your relation to the client?
*
I would like to have my attendance certificate logged with the Lightning Process Head Office
*
Yes
No
I wish to receive occasional and relevant correspondence about developments in the Lightning Process
*
Yes
No
I give my permission to be contacted at regular intervals to monitor my progress for the purpose of further research into the Lightning Process
*
Yes
No
6: Emergency Contact
So that we can contact someone closet to you in the case of an emergency please provide:
Emergency Contact Name
*
Emergency Contact Cell Number
*
Submit
Home
About Jodie
My Story
Features
Lightning Process
What Is The Lightning Process?
Applying
Dates & Fees
FAQ
121 Coaching
Testimonials
Lightning Process
Coaching
Contact