RYSE Intake Form | Harnett Healing

Date of Birth(Required)

Email(Required)

Phone(Required)

Occupation(Required)

Emergency contact name:(Required)

Relationship to you:(Required)

Do you have children? Y/N (Please give Names and ages)(Required)

Have you received energy work in the past? Y / N (if yes, what kind?)(Required)

Did anything not work for you with the energy work that you received in the past? Y / N (if yes, What didn't work?)(Required)

Have you participated in RYSE before? Y / N(Required)

How would you describe your current physical health?(Required)

Are you currently under the care of a physician? Y / N(Required)

If yes, please list name and purpose:(Required)

Are you currently taking any medications? Y / N(Required)

Have you suffered any physical/emotional trauma? Y / N(Required)

Please describe the trauma:(Required)

Did you seek help for the trauma? Y / N(Required)

What kind of help worked best?(Required)

How would you describe your current emotional health?(Required)

Are you currently under the care of a mental health professional? Y / N(Required)

What are your current self-care practices?(Required)

How would you describe your diet?(Required)

What do you hope to gain from this workshop?(Required)

What area(s) of your life do you want to improve?(Required)

What is your biggest concern coming into the workshop?(Required)

Is there anything else that you would like us to know about you?(Required)

Do you have any questions?(Required)

Physical issues you would like us to work on during the group clearings:(Required)

Emotional issues you would like us to work on during the group clearings:(Required)

Things you want more of in your life:(Required)

Things you want less of:(Required)

Anything else you'd like to add?(Required)

To be added during class I think I have cords with:(Required)

Expectations from:(Required)

Hurt inner children (big or little trauma with age & what happened):(Required)

Welcome and thank you for signing up for this RYSE series! Please read the following and initial each line. Your initials serve as proof that you have read, understood, and agree with each item.

Date

Type in your full name to sign.(Required)

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RYSE courses

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