Awakening Through Grief 6 Week Mindful Grieving Yoga Therapy Program
Please complete this form to sign up for our 6 week program.  Once your submission has been received and reviewed, you'll receive an email to connect and confirm acceptance into the program, let you know next steps with payment and things to know before first meeting.  Know that all responses will be held in complete confidentiality.  If you have any questions, need help with this form, or want to discuss the program, please email me at jen@apanii.org or call to discuss: Jen, 406-471-6423. Thank you!
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Email *
1. Full Name *
2. Email
3. Phone Number
4.  Is it okay to leave a private voice message? * Mark only one oval.
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5. Mailing Address
6.  City
7.  State
8.  Zip Code
9.  Pronouns
10.  What is the best way to contact you?  
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11.  Birthdate
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12.  Occupation
13.  Marital Status
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14.  Do you have children?
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15.  Do your children live at home?  
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16.  Have you ever participated in an Apanii or Grief Support Network Yoga Therapy Program in the past?
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17.  If so, please list the start date of the program and anything else you'd like to share about your experience.
18.  Emergency Contact
19.  Emergency Contact Email Address
20.  Emergency Contact Phone Number
Background Information
21.  Have you been clinically diagnosed with a Mental Illness?
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22.  If Yes to living with a mental illness, please explain and whether you are or are not in the care of a Licensed Mental Health Councilor or Therapist.  
23.  What kind of loss have you experienced?  (Check all that apply.)
23.  When did your losses occur
24.  How is your loss affecting you now?
25.  Have you had more than one loss in the last 5 years?
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26.  Are you currently in Counseling or receiving care from a Mental Health Therapist?
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27.  What is your current support system?
28.  Have you experienced any events that you would consider traumatic, whether related to this loss or not?
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29.  If so, please explain.
30.  Have you ever attempted or considered suicide?
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31.  If so, was there any follow up treatment? If so, what?
32.  Are you currently taking any medications for depression, anxiety or other mental health issues?
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33.  Have you ever been hospitalized for psychiatric reasons?
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34.  If so, please explain.
35.  Do you experience fighting in your household?
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36.  If so, please explain.
37.  Do you currently practice Yoga?
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38.  If yes, please briefly describe the nature of your yoga practice.
39.  What other activities do you do to support yourself on regular basis?
40.  Please describe any injuries, acute or chronic, or disabilities that your Facilitator should be aware of that may/will effect your practice.  
41.  Are you currently pregnant?
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42.  Please tell me why you are interested in participating in the Awakening Through Grief 6 Week Yoga Therapy Program?
43.  Is there anything else you would like for me to know?
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