Intensive Participant Questionnaire

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Questionnaire For HeartLand Intensive Participant
"A Private, Self-Healing Sanctuary In The Ozark Mountains" 

Coming to an Intensive? Print out this questionnaire. Filling it out can help focus intention. Be willing to release expectations. Bring this with you to HeartLand.
 
Name:
Daytime Phone: Evening: Fax:
Address:
Emergency Contact Name: Phone:

My reasons and purpose for wanting to be at HeartLand are:

What I hope to have accomplished by the workshop end is:

What I hope to gain while at HeartLand is:

A one line sketch of each of my three earliest memories of conflict:

1.

2.

3.

A brief description of conclusions I recall reaching, based on each of the above memories:
Memory (1)
Memory (2)
Memory (3)
Life is…    
I am…    
People are…    
I feel...    
Relationships are...    
I must…    
I need…    

My three biggest challenges I am willing to face and heal are:

1.

2.

3.

The way these challenges are manifesting in my life are:

I am willing to receive support in healing the following issue(s):

 

 


 

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