Florida Noble Man Participant Questionnaire

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Welcome to the Noble Man 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. What are your main issues (complaints, fears, pain, resentments) with women? *

(ie. Where, if at all, do you feel shut down, not seen, not valued or appreciated by the women in your life, or women you encounter?)

6. Have you ever been abused by women (either sexually, physically, emotionally or mentally)? If yes, please give specifics, include by whom, what age(s) and under what circumstances? *

7. How was your relationship with your mother as a child and what is your relationship with your mother like now? If your mother has passed away, what was it like before her death? *

8. As your mother was the first woman in your life, how do you see that your relationship with your mom has influenced your relationship with women, both in terms of the challenges as well as what is working well? *

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

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

11. What might stop you from receiving this? *

12. What does your ideal relationship with women look like? *

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

14. What do you see is possible for you if you were to live your highest potential as a man? *

15. 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. Are you willing and able to sleep on a mattress on the floor? *

Yes

2. Do you snore? *

Yes

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

Yes

Health and Well Being

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 you follow a stricter diet than that, or have specific food preferences/allergies please be prepared to supplement your meals as needed.

2. Do you exercise regularly? *

Yes

If yes, what kind?

3. Do you have any current physical disorders, mobility issues, health concerns, or history of health problems? *

Yes

If yes, please describe in detail:

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

4. Do you have a history of drug or alcohol abuse? If yes, what kind, and are you still using? Please explain 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.

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

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

7. Have you struggled with, been diagnosed with, or hospitalized for any of the following conditions in the past 10 years? *

(Psychosis, bipolar disorder, major addiction, self-injury (for example cutting), suicide attempt, PTSD, panic attacks, or major addiction?)

Yes

If yes, please explain:

(Include whether or not you've been diagnosed or hospitalized within the last year)

If yes to either questions 6 or 7, we 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

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

9. Have you ever been convicted of a crime? *

Yes

If so, for what were you convicted? *

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 emotionally, mentally, 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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