Good Grief Intake Form
Welcome to our Good Grief community. Our 6-week offering of modern healing tools for young people navigating grief begins on Sunday November 8. We'd love for you to join us on this healing journey.

This form serves as your intent to join Good Grief. It allows us to get to know you a little better, and for you to ask any questions you may have of us! Once received, we'll send you a note with next steps and payment info.

The information you provide in this form allows us to support you best. Please note that everything in this form, and all communication moving forward are confidential.

We look forward to meeting you,
Chloe, Aliya and Mica
goodgrief@moveandmindful.com
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Your Name *
Your Email Address *
Your Phone Number *
Where do you live? *
We'd love to learn more about you! Please tell us what you love to do, what's a normal day for you, and anything else you'd like to share.
Tell us a little bit more about your experience with grief and loss.
Have you been a part of other support groups or explored other forms of therapy?
Do you have experience with meditation or breathwork? If yes, please tell us a little more.
Please let us know if you are experiencing any major physical health concerns (e.g. major illnesses, recent surgeries, significant injuries)
Do you have any questions for us about the Good Grief work-group, the weekly schedule, our story or Aliya's teaching style?
Would you like to set up a 15-min info call with Aliya to chat through any questions or concerns? If yes, please let us know some times that are best for you, including what timezone you're in!
I consent to participation in the Good Grief work-group, which I understand is not led by mental health professionals. I am aware that this group deals with  highly emotional subject matter, and includes deep meditation experiences and breathwork with Aliya Daniels of Move & Mindful. I acknowledge that these experiences may bring to the surface memories, sensations and strong emotions. I am fully responsible for myself and my well-being and understand that it is my responsibility to communicate any questions or concerns to the Good Grief team. I am fully responsible for myself if I am experiencing heightened feelings of depression and anxiety, or feel like I want to hurt myself or others, and will seek professional support beyond this work-group. My experience will be held in confidential boundaries unless my safety is a concern. *
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