Professional Love Mentor® Application

Name

First Last

Address

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

Age

Phone - Office

Phone - Home

Phone - Cell

Preferred Email Address

Current Occupation

Academic Degrees, if any:

Additional growth courses or training

Number of years in clinical or coaching 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