Individual Services Interest Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We cultivate Circles of Care through healing justice frameworks that embolden practitioners to integrate radical love and belonging in their homes, classrooms, communities, and beyond. De Corazon envisions a safe and equitable world where restorative interactions transform individuals, relationships, communities and systems through the prevention, repair and deep healing of harm.

Full Name

Preferred Method of Contact (Phone/Email/Social Media)

We bring an intersectional analysis of systemic oppression and movement building to teach the critical skills needed to change behavior, interactions, conflicts, internal dynamics, and organizational culture. What services are you interested in? (Include all that apply)

Personal Transformational Coaching/ Mentorship

Elder Certified Circle Keeper Training

Circles of Care (Unpacking Resiliency: Collective Healing Spaces, Guided Liberation)

Circles of Care (Cultivating Authentic Leadership: A Healing Informed Praxis)

Please explain why you are interested in the service(s) you selected?

What is your desired timeline?

Single Session

Under 3 months

3-6 months

7 months - 1 year

1-5 years

Other:

Clear selection

What do you look forward to learning?

Circle Process

Developing Authentic Leadership

Deepen relationships with myself and others

Relaxation Techniques

Breathwork

Accessible Movement

Medicines

Other:

What type of training have you already received?

Identification of Personal Values

Restorative Justice Fundamentals

Transformative Justice / Community Accountability

Popular Education

Non-Violent Communication

Circle Keeping

40 Developmental Assets

Mental Health First Aid

Adverse Childhood Experiences (ACEs)

Trust Based Relational Intervention (TBRI)

Anti-Racist/Anti-Biased Training

Diversity Equity & Inclusion Training (DEI)

Community/Movement Based Training

Land Acknowledgement Process

Other:

I feel fulfilled at this stage of my life

not really

big time

Clear selection

I talk kind and am encouraging of myself

not really

big time

Clear selection

I know how to manage my stress

not much

yes big time

Clear selection

I have given my all to grow and fulfill my purpose on Mother Earth the past month

not really

yes big time

Clear selection

I am open to feedback from those that truly care about me

not really

big time

Clear selection

3 highlights from the past season have been...

What are the blocks? (vent here with no need to explain anything. List the real blocks and the ones that sometimes pop up in your mind, even made up ones, in the end they all have impact so its good to name them)

Activities that I do to raise my vibration, mood and confidence are...

What are some skills, potentials, interests that you carry?

The gifts I have to offer the world are...

What I learn will benefit me and my community because...

Who can I buddy up with and share my goals, obstacles, and visions with that will support me in my highest fulfillment?

I would like the facilitators to know...

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms