Registration Form

Please complete this form to register. We're excited to have you!

First Name

Last Name

Email *

City

Phone *

State

Are you experiencing any of the following challenges? Choose one or more.

Difficulty sleeping or disrupted sleep patterns?

Persistent feelings of anxiety or overwhelming stress?

Ongoing depression or pervasive feelings of sadness?

Emotional or mental health concerns affecting your daily life?

Other

Full Name of Emergency Contact

Preferred contact method *

Call

Zoom

Text

Email

Please share where you found us 🙂 *

Google Search

Social Media

Referred by a friend

Other (add to message below)

Describe the motivations and aspirations driving your interest in this scholarship, how it will support your wellness objectives, and anything else you would like me to know.

By checking this box, I agree to terms & conditions provided by the company and acknowledge and agree to participate in case study questions to support research for the Living Life Purple Foundation and to complete the intake form.