reCovery Program Introduction Form

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Please take a moment to fill out this form. Your input is immensely valuable to us. Find a comfortable spot, take your time, perhaps brew a warm cup of tea or light a candle. This marks your initial step in the journey of recovery and our shared path ahead. Rest assured, the information you provide will remain confidential and will solely be used to tailor our program offerings to better meet your needs.

First and Second Name *

Your e-mail address *

Your experience in movement practice *

I have no experience

I have some experience

I've been practicing for years

Any other experience? *

work with emotions

meditation, mindfulness

Let us know a bit more about your best practices and resources you already know

Please indicate your familiarity and experience with Polyvagal Theory
*

I have no experience

I have a moderate level of understanding and I'm aware of my various states of the Autonomic Nervous System (ANS)."

I have an extensive level of understanding and already apply various techniques for self-regulation

Please indicate your familiarity and experience with working with Inner Parts
*

I have no experience

I have a moderate level of understanding and am aware of my internal parts and their impact on my behavior.

I have an extensive level of understanding and already apply various techniques for overall better well being and integration

Please indicate your familiarity and experience with working with Attachment Theory
*

I have no experience

I have a moderate level of understanding and am aware of my Attachment Styles

I have an extensive level of understanding and am able to overcome my habits in relationship dynamics.

Please share a brief overview of what has led you to join this program. We want to emphasize that we do not intend to trigger any traumatic memories through your writing. Our goal at this stage is to gain a general understanding of where you currently stand on your path to recovery
*

Is there anything else you would like us to know?

What are your expectations? What would you like to gain after you complete this program? *

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