Professional Love Mentor® Application We respect your privacy and have a strict policy about not sharing information Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AgePhone - OfficePhone - HomePhone - CellPreferred Email Address* Current Occupation*Academic Degrees: (remember, you need a minimum of a Master’s degree in a mental health discipline)*Additional growth courses or trainingNumber of years in clinical practice*Are you in a committed love relationship?*YesNoIf so, for how long?In your opinion, what is the most difficult thing about love?*In your opinion, what is the greatest thing about love?*Have you read Love in 90 Days and/or Sealing the Deal?* Yes No Have you used principles from Love in 90 Days and/or Sealing the Deal in your practice?* Yes No If so, how?Have you used principles from Love in 90 Days and/or Sealing the Deal in your personal life?* Yes No If so, which principles or techniques?Briefly tell us about a successful case in which you helped a woman get married or create a good love relationship.*What three things did you do that helped this client achieve this result?To your knowledge, are they still together? Yes No Tell us about a case in which you were unable to help a single woman find or stay in a love relationshipWhat do you enjoy most about doing clinical work with women?*Are you a member of any professional organizations?* Yes No If yes, what are they?What do you dislike about doing clinical work with women?Do you enjoy the process of clinical supervision?* Yes No What do you like & dislike about the process?*Have you ever been brought up on ethics charges?* Yes No If yes, what was the reason and outcome?Is documentation available to verify what happened? Yes No Have you ever been sued for malpractice?* Yes No If yes, what was the reason and outcome?Is documentation available to verify what happened? Yes No Have you ever been asked to leave a professional association?* Yes No If yes, what was the reason and outcome?Is documentation available to verify what happened? Yes No Would you be willing to sign non-compete and non-disclosure contracts relating to the referrals, clients and procedures of the Love Mentoring® group?* Yes No Are you willing to conduct at least 10 Love Mentoring® hours per week by phone or Skype? (you need to be able to do at least 10 hours per week to be eligible)* Yes No How many Love Mentoring® hours would you like to do per week?Do you feel like you have a life purpose?* Yes No If so, what is it?Why do you want to be a Love Mentor®?*What are the top three reasons you would like to work with Dr. Kirschner?*How do you see being a Love Mentor® as a support to your professional career?*Is there anything else that you think we should know about you or is there anything else that you would like to tell us?