Regional Forum Application

Personal InformationForum location:

Other location name:

Name:

Email address:Phone number:

What is your Enneagram Type (if known)?:

Organization Information

Name of Head of Organization if not you

Is the head of the organization familiar with The 15 Commitments and interested in role-modeling-conscious leadership?

Do you have direct reports? If so, how many? Leave blank if none.

How many people work at your organization?

Forum Information

Why is being a conscious leader important to you?

What is your experience with personal development and self-awareness?

Have you read The 15 Commitments of Conscious Leadership?YesNo

Have you attended a Taste or an Intro?YesNo (If you answer No, we recommend doing a Taste prior to attending a Forum. Register for a Taste here)

Why are you interested in joining a CLG Forum?

Tell us in two sentences why you will be a net positive impact to a forum of peers; what is the special gift you bring?

Are you in an intimate relationship? If so, how does your partner or do your partners feel about you doing this forum? Are they interested in doing their own inner work as you participate in this forum?

Are you willing to reveal all significant secrets and withholds to any relevant parties by the end of this forum?YesNo

Registration AgreementsI agree to:Take 100% responsibility for my physical, emotional, mental and spiritual well being throughout the Forum.Stay curious in the face of all challenging feedback, including looking at the opposite of all of my stories.Be deeply curious and willing to question all of my beliefs.Commit to giving direct feedback with your peers and facilitators.Attend all 10 sessions.Attend all in person retreats.Show up for a 30-minute learning partner practice once a week.Spend a minimum of 15 minutes per week to respond to the weekly prompts on Slack.Give a 10 minute meditation practice 5-7 days a week.Participate for the entire session, including arriving on time and staying until the end.

Mental Wellbeing AgreementShould deeper psychological triggers get activated, I agree to take responsibility for getting outside support from a medical or psychological professional. I understand that this is not a therapy forum.To best support you, please provide the following confidential information:

Are you currently under the care of a psychiatrist or psychologist?

YesNo

Are you currently taking any medications for emotional/mental challenges?

YesNo

Have you ever been hospitalized for psychiatric care or any mental/emotional disorder?

YesNo

Have you ever had a "nervous breakdown" or been diagnosed with any of the following: bipolar, schizophrenia, obsessive compulsive, borderline, PTSD, or psychotic disorder?

YesNo

Have you ever attempted suicide?

YesNo

If yes was selected on any above, are you willing to have your doctor write a written statement okaying you for this forum?

YesNo

Who will be paying for this Forum?

My company is paying for my Forum

I’m paying for my Forum

Confirm that my company is paying for my Forum

Company Address (for billing purposes)

Confirm that I am paying for my Forum

Personal Address (for billing purposes)

Is there anything else you would like us to know?

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Regional Forum

A group of like-minded organizational leaders who come together to practice consciousness and conscious leadership together.

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