Please note that "The Shift" is NOT for you if you:

Are looking for a quick fix.
Are not willing to take responsibility of your own emotions, state, and outcomes/results.
Are looking for more reasons why life is the way it is.

First Name of Parent *

Last Name of Parent *

Phone *

Email *

As a parent, what are your 3 greatest challenges? *

Where would you like to see your child in 7 years time? *

What would you like to get out of participating in "The Shift"? *

On a scale of 0 to 10 (0 being not at all and 10 being whatever it takes) How committed are you to change the things that aren't working?

Please enter details of all children you wish to participate in "The Shift". If you have more than 4 children you wish to participate, please add details in the message box at the end of the form. If you have less than 4 children, please leave unrequired spaces blank.

Child 1

Child 1 Full Name *

Child 1 Age *

What are Child 1's 3 greatest challenges? *

What are you (child 1) wanting to get out of or learn from this program? *

Child 2

Child 2 Full Name

Child 2 Age

What are Child 2's 3 greatest challenges?

What are you (child 2) wanting to get out of or learn from this program?

Child 3

Child 3 Full Name

Child 3 Age

What are Child 3's 3 greatest challenges?

What are you (child 3) wanting to get out of or learn from this program?

Child 4

Child 4 Full Name

Child 4 Age

What are Child 4's 3 greatest challenges?

What are you (child 4) wanting to get out of or learn from this program?

How can we help?

How specifically can we help you and your family? *

Is there any further information you wish to provide us with?

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