Welcome

Thank you for participating in this free event. This form is required to book a free Reflection Call with Shaina Scott. After this form is submitted, you will be automatically redirected to a page to schedule your free video call.

The form will (1) indicate to Shaina what topics or questions you would like to spend your 15 minutes addressing and (2) important information about the event.

First name

Last name

Preferred Nickname (Optional)

Phonetic Pronunciation Of Name

What are your preferred pronouns?

She/Her

He/Him

They/Them

Email

Please confirm your email

If during your call, you request any follow-up information or links to self-discovery opportunities from our organization or partners, you can expect to receive the requested follow-up materials in your email within 5-7 business days after the Reflection Call Event has ended.

I confirm.

What is your Instagram handle? (Optional)

If you have sent information within direct messages to Shaina Scott's Instagram account in the past, this allows Shaina Scott to review messages for familiarity prior to meeting you.

Secondly, if your direct message was missed in the past, this allows Shaina Scott to revisit important message streams that require attention.

You can optionally supply this information if either of these situations apply to you.

What is your current level of education around Nervous System Regulation and Applied Polyvagal Theory?

Today's Date