Reaching out for help is an incredibly brave and important step. I hope you are proud of yourself for taking it, and I sincerely hope that I can be part of your journey.

To apply to work with me, please fill out the form below. While I would love to be able to help every person in the world, this is simply not possible. Still, I do read each application carefully, and I reply to everyone who applies.

The more information you can provide me with, the better. Please don't hesitate to be completely honest and open. Please email me at coaching (at) vironika (dot) org if you have any questions.



Birth Date (yyyy-mm-dd)

Street Address

City, State/Province


Zip/Postal Code


What would you like help with?

Have you sought help elsewhere? Where? What was the outcome?

What do you believe is your greatest obstacle to healing and happiness?

What do you want to experience?

Why do you want to work with me?

Where did you first hear about me and my work?

Are you willing to...
Be open-minded
Step outside of your comfort zone
Communicate openly and honestly
Take responsibility for your own progress
Commit yourself to a minimum 6 months of weekly sessions

After we're finished working together, are you willing to...
Write a review/testimonial about our work together
Recommend me to anyone you think would benefit from coaching with me

Please note: ALL of the above must be checked off in order to submit the form. Send button will not activate until all conditions are accepted. If you have any concerns about the items above, please state them in the Comments section below.