FL COR Woman Intake Questionnaire

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Welcome to the FL COR Woman 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. These questions might be challenging, and we encourage you to answer all of the questions as honestly and completely as possible. All answers are considered strictly confidential. Your responses don't need to be long, as a few sentences that are specific will suffice.

Email *

Legal Name *

Name I like to be called *

Age *

Referred By *

Relationship Status *

Number of children *

Ages of children

Occupation *

1. Previous transformational and group experiences *

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

2. What are your current spiritual practices and affinities? *

(Formal or Informal)

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

4. 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, war etc)

5. In what areas in your life (if any) do you struggle to appreciate, nourish, or value yourself? *

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

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

8. What might stop you from receiving this? *

9. As this is a workshop for women only, how do you relate to yourself as a woman? *

(Please include how you relate to your own body, to other women, to your mother and your feminine lineage)

10. What fears, if any, do you have about your participation? *

11. Is there anything else you’d like us to know about you? *

Sleeping Accommodations

We will do our absolute best to accommodate you in your sleeping arrangements. (Note: If you received financial assistance, please be prepared to be flexible with sleeping accommodations.)

1. We sometimes ask participants to be flexible with their sleeping arrangements. Please check all that apply: *

I'm willing to sleep on a mattress on the floor

I'm willing to share a larger bed with another woman participant/friend

I'm not willing to do either of those options

Required

2. Do you snore? *

Yes

3. Are you able to sleep in a room with someone who snores? *

Yes

Health and Wellbeing

We care about you and your needs and do our very best to accommodate you whenever possible.

1. Do you have any special dietary needs? *

If you have a specific food allergy, please note what it is. We accommodate gluten free and dairy free. If have specific food preferences/allergies, other than mentioned above, please be prepared to supplement your meals as needed.

2. Do you exercise regularly? If yes, what kind? *

3. Are you pregnant? If yes, how far along will you be at the time of the workshop? *

4. Do you have any current physical disorders, mobility issues, health concerns, or history of health problems? If yes, please describe in detail. *

(Please include whether or not you've been hospitalized within the last year)

5. Do you have a history of drug or alcohol abuse? If yes, are you still using? Please describe in detail: *

(Please know, because of the deep inner work you will be doing, recreational drugs and alcohol are not permitted for the entire length of your stay with us, and you are expected to arrive sober.)

6. Are you currently in therapy, counseling, or coaching? If yes, what kind and how often? *

7. 7. Are you currently taking any psychiatric medication? If yes, for what condition? *

8. 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

If yes, we may require a note from your attending medical professional stating that this retreat will be safe for you. Are you able to provide this? *

Yes

Not Applicable

If no, please explain why not

9. To what extent have you experienced intense interpersonal conflicts, anger with friends, or cut offs in important relationships? *

In case of emergency, whom should we contact? *

Name

Relationship to you *

Cell Phone Number *

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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