Name: | ||
Daytime Phone: | Evening: | Fax: |
Address: | ||
Emergency Contact Name: | Phone: | |
My reasons and purpose for wanting to be at HeartLand are: |
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What I hope to have accomplished by the workshop end is: |
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What I hope to gain while at HeartLand is: |
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A one line sketch of each of my three earliest memories of conflict: | ||
1. 2. 3. |
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A brief description of conclusions I recall reaching, based on each of the above memories: | ||
Memory (1)
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Memory (2)
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Memory (3)
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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: |
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1. 2. 3. |
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The way these challenges are manifesting in my life are: |
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I am willing to receive support in healing the following issue(s): |
SCHEDULES & RELATED INFORMATION