Name

Email Address

Phone Number

Home Address

Date of Birth

Please tell me a little about what has drawn you to this program?

Please tell me about the things you are seeking to change or discover about yourself?

Have you had therapy previously? Have you had therapy previously?Comprehensive TherapySome TherapyNo Therapy

Have you participated in Somatic therapy or Trauma Resolution therapy? Have you participated in Somatic therapy or Trauma Resolution therapy?SomaticTrauma ResolutionBothNo I have not had either of these

Is there a specific reason, such as a trigger, that has led you to seek support at this time?

10. Are you committed to your own healing and willing to take responsibility for putting in the work that needs to be done to reach your desired changes? (HINT: I need you to select 'YES' if we are going to work together) 10. Are you committed to your own healing and willing to take responsibility for putting in the work that needs to be done to reach your desired changes? (HINT: I need you to select 'YES' if we are going to work together) YES! No

Have you been diagnosed with any mental health conditions? (PLEASE NOTE: This does NOT impact your application, however, it is important for me to be aware so I can best understand your needs) Have you been diagnosed with any mental health conditions? (PLEASE NOTE: This does NOT impact your application, however, it is important for me to be aware so I can best understand your needs) Yes No

If applicable, please provide a brief description of your diagnosis

Acceptance Acceptance This form has been completed by the person named in the application. All of the information provided above is true and correct and I confirm that I am genuinely seeking help. I understand that this is only an Expression of Interest. It is not a guarantee of a place in any future program.