Date of birth
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Gender
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Occupation
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Have you completed a confidential questionnaire for a residential workshop you have attended with us in the past 6 months
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Your family, and how & where you grew up
(Please include the relative ages of any siblings)
Your education & career
Your current lifestyle – including exercise, diet, sleep, self-care
Your relationship status, history, duration and major issues during relationships?
How you describe your sexual orientation?
Do you have a spiritual practice or belief?
Do you have children?
If so, please give names and ages.
Have you ever been in therapy? If yes, please describe
Have you ever received outpatient or inpatient care for mental health issues, or been prescribed medication for an emotional issue? If yes please give details
Do you have any physical injuries or limitations?
Is a doctor treating you? If yes, please list conditions and treatments?
Are you currently taking any prescribed medication? If so, please elaborate
Do you have any history as the victim or perpetrator of violence, or the crossing of personal boundaries? If yes, please explain.
Have you ever been suicidal? If yes, please explain.
Have you ever experienced flashbacks or extreme fear about physical touch? Do you have any memories of physical, sexual, emotional or ritual abuse? If yes, please explain.
If you use recreational drugs or alcohol please state drug, frequency and amount per week
What are / have been your addictions?
What brings you to this workshop, what would you like to get out of it?
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If you got what you wanted, how might this affect your life?
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Can you think of any ways in which you might unconsciously sabotage yourself during the workshop?
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Is there anything else we should know or you would like us to know?
For the benefit of myself and other participants, I am willing to switch off my phone and other electronic devices, and to suspend contact with people outside of the workshop for the duration of the workshop?
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I understand that I will need to be at all the sessions during the workshop, and that if I miss sessions or try to join the workshop late I may not be able to attend.
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I understand that this workshop is not designed for the rehabilitation or treatment of PSTD, complex PTSD or developmental trauma.
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(If you have suffered from trauma, PTSD, or any other mental health condition, it is essential that you give details on the form above. Moreover, if you have concerns about whether the workshop is suitable for you due to these conditions it is essential that you discuss this with Ed, and if appropriate seek the advice of a mental health professional.)
Though there may be therapeutic benefits, I understand that this workshop is not a substitute for psychotherapy and that the facilitators are not psychotherapists.
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If you have questions or are not able make any of these agreements please explain below;
