Health Intake

A confidential reflection before we begin.

Health Questionnaire — Please take your time with each question. Your answers help me understand your world before we meet.

Full Name

Email Address

1. Where were you born?

2. Which languages do you speak?

3. Why do you want to participate in the retreat? Is there a specific issue you wish to work on?

4. Please write freely about your daily routine.

5. Please write freely about your relationship with your parents (past and present).

6. Do you have or have you had any bodily illness? If so, please write your history with that.

7. Do you or have you had any mental illness, phobias, depression, or anxieties? If so, please write your history with that.

8. Are you taking or have you taken any chemical drugs (pharmaceutical as well as recreational)?

9. Do you have any brothers or sisters? How are your relationships?

10. Are you currently having any health issues?

11. Do you have any experience with natural plant medicines and/or psychoactive plant medicines? Please describe.

12. Please share a dream that you have about your life, happiness, and freedom.

13. Please write about some of your biggest fears.

14. Please write about your relationship with God. Thoughts, feelings, doubts, etc.

15. Please write freely about your sexuality, from your early experiences till now.

16. Please write freely about your relationship with money.

17. What do you believe about love?

18. Do you have any addictions? If so, please share about it.

19. Please write freely about your family constellation (partner, children, and your living situation).

20. For women: please write about your menstrual cycle.

21. What is your current occupation? Do you enjoy it?

22. Please share about life traumas you have experienced and your healing path around these issues.

23. What is your hope or desired outcome for this retreat?

24. What are your joys in life?

25. Have you ever suffered from depression?

26. Please write about experiences you have had with other forms of therapy.

27. Are you currently in any self-healing process or working with a therapist?

28. Please write about your relationship with your body.

29. Please describe your relationship with religion and spirituality.

30. How are your daily energy levels?

31. Please describe your sleep patterns.

32. Do you have dreams? Please share openly about your dreams.

33. Please describe your eating habits.

34. Have you had or do you currently have emotional eating issues? Please describe.

35. Do you smoke tobacco or marijuana? Please describe.

36. What forms of therapy have you experienced that were meaningful for you?

37. Please describe a meaningful moment, event, or experience in your life.

38. Please describe a meaningful relationship in your life.

39. Is there anything else that you want to share with us?

40. Do you have any heart problems, history of seizures, panic attacks, breathing problems, asthma, or any other health situation that may affect your participation in the retreat?