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Emergency Contact *

Emergency Contact Relationship *

Emergency Contact Phone *

Please list herbs or medications that you are currently taking (including cannabis, caffeine, tobacco, alcohol, and sugar): *

Living Situation *

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Which of these feelings/emotions describe your current experience of life? *

Joy

Happiness

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Connection

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Groundedness

Anger

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Fear

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Describe your ability to be present with and express feelings and emotions: *

Are you satisﬁed with your living conditions and work life? Please explain: *

Please describe your experiences of physical or emotional trauma and when they occurred: *

Do you have healthy boundaries in your life? Please Explain: *

Please describe your spiritual practices: *

How would you like to see things shift in your life? *

What things are you or are you not willing to release? Please explain: *

Are you willing to make major changes in your life to allow these things to happen? *

Yes

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