Waves 4 Women intake form

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Please complete the following questions prior to participating in Waves 4 Women therapeutic surf program.

Email *

Name *

Address

Phone number *

Please rate your level of satisfaction in the following areas of your life (from 1-5) *

1 = Very disatisfied 5 = Very satisfied

N/A

intimate/romantic relationships

parenting

family life

social life/friendships

employment or education

financial situation

recreation/leisure

physical health

emotional health/wellbeing

spirituality

Have you had any major illnesses, injuries, or hospitalizations recently? *

yes

If "yes" to above, please describe

Please rate your comfort swimming in the ocean *

extremely uncomfortable/inexperienced

extremely comfortable

Please describe your experience with surfing (no experience is necessary) *

Please describe any social, emotional, or environmental stressors or challenges you are currently dealing with (anxiety, depression, ptsd, grief, substance abuse, family conflict, social isolation, financial difficulties, etc)

How would you describe your personal strengths? *

What do you hope to gain or learn through participation in Waves 4 Women therapeutic surf program? *

Please provide any additional information you would like us to be aware of

Submit

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