Men's Immersion Intake Questionnaire

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Welcome to the Men's Immersion workshop. The following questionnaire is designed to give the facilitators the necessary information to ensure you a safe and rewarding experience. As with most things you will only receive back what you put into it. All answers are considered strictly confidential. Your responses don't need to be long, as a few sentences that are specific will suffice.

Email *

Name *

Age *

Referred By *

1. Previous transformational and group experiences *

(i.e. workshops, therapy, coaching, counseling, 12-step, etc)

2. Describe briefly the most elated/joyful times of your life. Please include what it was about these times that made you so happy and what they meant to you. *

3. Describe briefly the most traumatic experiences in your life: *

(Please include any of the following that have happened to yourself or a loved one/family member: Absent parent(s), divorce of parents, physical, sexual or emotional abuse, adoption, miscarriages, early death, suicide or attempted suicide, prolonged illness, major injuries, mental disorders, public shaming, religious trauma, war etc)

4. What is it you’d like to let go of, or heal during this weekend? *

5. What is it you’d like to receive from this weekend? *

6. As this is a workshop for men only, how do you relate to yourself as a man? *

(Please include how you relate to your own body, to other men, to your father and your masculine lineage)

7. Have you struggled with, been diagnosed with, or hospitalized for any of the following conditions in the past 10 years? If yes, please describe in detail. *

(Include whether or not you've been diagnosed or hospitalized within the last year) Conditions include: Psychosis, bipolar disorder, major addiction, self-injury or suicide attempt (for example cutting), PTSD or panic attacks

8. Are you currently taking any psychiatric medication? If yes, for what condition? What kind and what dosage? *

9. There are processes in the Immersion that can be emotionally challenging. Have you ever felt psychologically or mentally unstable when you experienced intense emotion? If so, please describe what that was like for you and what helped you to feel stable again. *

10. While this is a supported space to help you evolve and reclaim yourself, it is an intense process facilitated in an online setting. Please let us know if you have any other concerns we should consider: *

I, the undersigned, certify that all of the above information provided is true and complete. Furthermore, I understand that portions of the workshop may be mentally, emotionally, and physically demanding. Therefore I have disclosed, to the best of my knowledge, all relevant information about my health and well-being that might have a bearing on my activities as I understand them.

Signed *

Dated *

YYYY

A copy of your responses will be emailed to the address you provided.

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