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In Person Healing Session - New Members

Before your free new member call, we ask that you complete this short assessment form. It helps us gently understand a little more about you, what’s bringing you here, and how we can best support you moving forward.

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Question 1 of 7

Have you been diagnosed with any physical or mental health conditions? If yes, please give details. 

Question 2 of 7

Are you currently receiving any therapy, counselling, or medical treatment? If yes, please give details. 

Question 3 of 7

Do you experience any of the following?

(Select all that apply)
A

Chronic Stress

B

Burnout

C

Panic Attacks or Anxiety

D

Emotional Numbness or Dissociation

E

Difficulty Expressing or Processing Emotions

F

Past Trauma Affecting your Daily Life

Question 4 of 7

Are you currently taking any medications that affect your mood, emotions or nervous system? If yes, please give details. 

Question 5 of 7

Have you experienced significant trauma (such as ongoing abuse, assault, or a major life-threatening event) 

A

Yes

B

No

C

Unsure

Question 6 of 7

Have you practiced somatic movement, energy healing, breathwork, or other body-based therapies before? 

A

Yes

B

No

C

Unsure

Question 7 of 7

Can you give a brief overview of what you are currently struggling with?

Confirm and Submit