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): |
SCHEDULES & RELATED INFORMATION