Kaleidoscope Intake Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number *DOB *Occupation *What are your expectations for the Kaleidoscope program? *What are you top three personal goals? *What are you top three professional goals? *What are you top three financial goals? *What are you top three creative goals? *What specific challenges or obstacles have you faced in achieving these goals in the past? *How would you measure success in each of these areas? *On a scale of 1-10, how motivated are you to make changes and achieve your goals? Selected Value: 5 “0” being not likely, “10” being very likely On a scale of 1-10, how satisfied are you with your current level of personal fulfillment. Selected Value: 5 “0” being not satisfied, “10” being very satisfied On a scale of 1-10, how satisfied are you with your current level of Career satisfaction. Selected Value: 5 “0” being not satisfied, “10” being very satisfied On a scale of 1-10, how satisfied are you with your current level of Financial stability. Selected Value: 5 “0” being not satisfied, “10” being very satisfied On a scale of 1-10, how satisfied are you with your current level of Creative expression. Selected Value: 5 “0” being not satisfied, “10” being very satisfied How often do you experience feelings of: Stress, Overwhelm, Procrastination, or Self-doubt? *NeverNot that oftenSometimesFrequentlyAlwaysWhat are your preferred learning styles? *VisualAudioHand’s OnCombinationIf other, please specifyConfidentiality is Key! NDA Agreement *Yes I Agree to this NDA StatementTo ensure a safe and trusting environment for sharing, learning, and growth, all participants of the Kaleidoscope program are required to sign this Non-Disclosure Agreement (NDA). By clicking yes to this NDA, you agree to: Keep all information shared within the program confidential. This includes, but is not limited to: Personal experiences and stories shared by participants Sensitive financial information Creative ideas and projects Specific techniques and strategies taught in the program Internal documents and materials Not use any confidential information for personal gain or outside of the program context. Not disclose confidential information to any third parties, including family, friends, or colleagues, without express written permission from the program facilitators. This NDA is valid for the duration of the program and for a period of 1 year after its completion. Breaches of this NDA may result in: Immediate dismissal from the program. Legal action. We value your commitment to confidentiality and appreciate your cooperation in creating a respectful and trusting learning environment for all participants. Please click yes to acknowledge your understanding and agreement with the terms of this NDA.Submit
