Insomnia Mastery Program: Application Form

1The Basics

2Present & Future You

3Coaching Process

4Final Submission

Your name:(Required)

First Last

Your best email address:(Required)

Your location:(Required)

What is your timezone?

Do you currently (or plan to) work shifts or have an irregular or unpredictable work schedule?(Required)

Yes

No

About you

Please rate the following statements and questions as honestly as possible:

I don’t mind deviating from my routines and plans if I have to.(Required)

1 = Not true at all. 10 = Completely true.

I am not easily discouraged by difficulties or failures.(Required)

1 = Not true at all. 10 = Completely true.

Trying my best at work and in my personal life makes a difference.(Required)

1 = Not true at all. 10 = Completely true.

I strive to be a little better through effort and practice.(Required)

1 = Not true at all. 10 = Completely true.

I recognize that challenges and failures are an opportunity for growth.(Required)

1 = Not true at all. 10 = Completely true.

When things don’t go as planned, I seek feedback from others to help me succeed.(Required)

1 = Not true at all. 10 = Completely true.

I am confident that I can perform effectively on many different tasks.(Required)

1 = Not true at all. 10 = Completely true.

In general, I think that I can accomplish outcomes that are important to me.(Required)

1 = Not true at all. 10 = Completely true.

When I am confronted with a problem, I can usually find several solutions.(Required)

1 = Not true at all. 10 = Completely true.

I can express my emotions directly, maturely, and honestly.(Required)

1 = Not true at all. 10 = Completely true.

When I’m faced with a stressful situation, I’m able to think about it in a way that helps me stay calm.(Required)

1 = Not true at all. 10 = Completely true.

I can manage my stress or emotions without relying on particular substances or behaviors to cope (e.g., food and eating, alcohol, drugs, shopping, scrolling social media, etc.)(Required)

1 = Not true at all. 10 = Completely true.

I know who I am, what I want, and what I don’t want.(Required)

1 = Not true at all. 10 = Completely true.

The way I am living reflects my deeper values.(Required)

1 = Not true at all. 10 = Completely true.

I connect my goals, and my actions towards those goals, with a deeper purpose.(Required)

1 = Not true at all. 10 = Completely true.

I can count on others when I need help.(Required)

1 = Not true at all. 10 = Completely true.

My surrounding environment promotes positive thoughts and actions around change.(Required)

1 = Not true at all. 10 = Completely true.

I have a close network of people with common interests, values, and goals.(Required)

1 = Not true at all. 10 = Completely true.

Optimists are people who look to the future with confidence and who mostly expect good things to happen. How would you describe yourself? How optimistic are you in general?(Required)

1 = Not at all optimistic. 7 = Very optimistic.

Pessimists are people who are full of doubt when they look to the future and who mostly − expect bad things to happen. How would you describe yourself? How pessimistic are you in general?(Required)

1 = Not at all pessimistic. 7 = Very pessimistic.

Your medical history

In the past 12 months have you been diagnosed with, or received medical advice or treatment for, any of the following:

(Please check any that apply)

Please list below any supplements and over-the-counter or prescription medications you take occasionally or regularly:

If none, you can leave this blank!

The coaching process

Coaching is a process of learning and skill development. It involves changing things that aren't working. Change is usually difficult. It can be scary. At yet, without change, nothing changes!

If your application is approved, I will work as your guide. I will give you my full attention. I will listen to you. I will not judge you and I will not tell you what to do.

My job is to help you get where you want to go and do what you choose to do. To help you uncover and use your strengths and skills to get you closer to where you want to be.

You will be setting the goals, you will be making the decisions, you will be responsible for the actions you decide to practice, and you will be the one accountable for your actions!

I am not here to help you try make a certain amount or type of sleep happen. You already know from experience that trying to control sleep only makes it more difficult.

I am not here to help you try to permanently delete the difficult thoughts and feelings associated with insomnia. You already know from experience that the more you try to fight or avoid them, the more powerful and influential they become.

And, I am not here to solve your problems for you — my job is to help you solve your problems. You are the expert on you. I am not here to fix you because you are not broken!

I am here to help you explore and commit to actions (something you can control) that will move you away from struggling with sleep (and the difficult thoughts and feelings that can come with insomnia) so you can move toward the life you want to live.

When there is less struggle, you will be better able to do things that matter to you, you will be better able to focus on where you are and what you are doing, and sleep will have the best opportunity to take care of itself.

The objective is for you to live the life you want to live, independently of sleep and even in the presence of difficult or uncomfortable thoughts and feelings. And, you will get there through your ongoing practice of committed and meaningful action.

Since you are responsible for making change happen, there is no money-back guarantee and there are no refunds. For coaching to be effective, you need to be 100% "all-in".

Does this kind of coaching sound like something that you’d benefit from? Why?(Required)

How the Insomnia Mastery program works

The Insomnia Mastery program runs for three months. We start with a one-hour Zoom or phone session (your choice) that will take a deep dive into who you are, where you are now, where you want to be, and why you want to get there. This is an opportunity for me, as your coach, to really get to know you and for you, as the client, to gain clarity on where you want to go and the changes you want to make. You'll also start to develop a vision statement that will be used to get you (and keep you) moving in the direction you want to be heading during our time working together.

If there's time, we'll also see if we can come up with one specific action you feel ready, willing, and able to take with you to practice after the session — an action that will help you move toward the future you have in mind for yourself.

From then on, you'll be able to book up to six 30-minute coaching sessions for the remaining 12 weeks of the program. These can be booked one at a time, depending on your need. Many clients like to start with one or two weekly sessions before spacing them out to every two or three weeks.

In each 30-minute coaching session, we'll explore how your practice went and any changes you might wish to make. We might also add another action for you to practice, too.

In addition to our scheduled coaching sessions, you will also have unlimited email access to me during your enrollment in the program and I will answer any emails you send me within two business days.

Now, some of the actions you try might not be helpful. They might not work. And that doesn't mean they're a failure. They are still learning experiences and just mean that we need to make an adjustment. What truly matters is taking meaningful action. Making changes. Being willing to experiment. Being open-minded and curious. Investing your time, energy, and commitment into the process.

By the end of our time working together, you will have a number of skills to practice independently of me — skills that will keep you moving toward the vision statement you created at the very start of the program. The place where, ultimately, you want to be.

What would it feel like to work through a program like this and have this level of ongoing support as you are working on making some changes?(Required)