Professional Love Mentor® Application

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Age

Phone - Office

Phone - Home

Phone - Cell

Preferred 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 training

Number of years in clinical practice*

Are you in a committed love relationship?*

Yes
No

If 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 relationship

What 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?

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Professional Love Mentor® Application