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Next Steps: Install the User Registration Add-On This form requires the Gravity Forms User Registration Add-On. Important: Delete this tip before you publish the form.
Tell Us About You Choose the services you are interested in:(Required) 1 on 1 Preparation and/or Integration Support 3-Day Expansive Space Intensive (individual) 3-Day Expansive Space Intensive (group) 5-Day Expansive Space Intensive (individual) 5-Day Expansive Space Intensive (group) Couple's Expansive Space Retreat Micro Expansive Space Support (Individual)
How do you feel about your given name?*(Required)
What is your Biological Sex?(Required) Does racial tension currently cause you, or your relationships, any stress or distress?(Required) Do current political situations currently cause you, or your relationships, any stress or distress?(Required) When you make decisions, what matters most?(Required) Are many of your decisions influenced by:(Required) What is more important to you?(Required) What is more important to you?(Required) What best describes you most of the time?(Required) What is your Relationship Status?(Required) (cont)
Medical Have you experienced Traumatic Brain Injury?(Required) Have you experienced an epileptic seizure?(Required) How would you describe your eyesight?(Required) Check all that apply
Perfect Pretty Good I am nearsighted I am farsighted I am nearsighted and I need glasses/contacts I am farsighted and I need glasses or contacts My eyesight is pretty bad My eyesight is pretty bad I am legally blind I am blind I cannot see with my right eye I cannot see with my left eye I have been diagnosed with red and green colorblindness Color blind
How would you describe your hearing?(Required) Check all that apply
Perfect I am hard of hearing I am deaf I am hearing impaired I have trouble hearing in my right ear I have trouble hearing in my left ear I use a hearing aid
Have you ever been diagnosed or experienced:(Required) Schizophrenia? Generalized Anxiety Disorder? Bipolar Type One? Mania? Psychosis? None of these?
Does anyone in your family have any history of mental illness, heart disease, high blood pressure or terminal illness?(Required)
Mental Health Have you ever had suicidal ideations or ideas of ending your life?(Required) Have you ever attempted suicide?(Required) Have you ever been bullied?(Required) Have you ever been a bully to someone else?(Required) Have you ever stolen anything from someone else?(Required) Have you ever physically assaulted anyone?(Required) Have you ever touched anyone in a way that you would consider inappropriate or against their will/desire?(Required) Have you ever had someone assaulted by another person?(Required)
Functional Do you take any prescribed medicine?(Required) Do you take any over-the-counter medicine?(Required) Do you take any vitamins/supplements?(Required) Have you EVER experienced any of the following in the PAST?(Required) Headaches Neck Pain Back Pain Shoulder Pain Hip Pain Knee Pain Ankle Pain Chest Pain Hand Pain Foot Pain None
Are you currently experiencing any physical body pains or aches?(Required) Do you have any past injuries that have created scars?(Required) Do you have any past injuries that DID NOT leave physical scars?(Required) Do you have any diagnosed or undiagnosed skin rashes or conditions?(Required) Are you currently sexually active?(Required) Do you enjoy sex?(Required) Choose all that apply
Yes No Sex is a big source of stress for me I do it only because I feel like I have to If I could have sex every day, I would If I could never have sex again, I wouldn't
Have you been tested for COVID-19?(Required) Please note that testing is not a requirement for attendance to our events unless specified.
Have you been vaccinated for COVID-19?(Required) COVID-19 Mask Considerations(Required) Please choose all that apply
I wear a mask because it is required I wear a mask because I believe it protects me I wear a mask because I believe it protects others If I did not have to wear a mask, I wouldn't I wear a mask because I believe that it shows I care for others I believe masks do more harm than good
How much time would you say that you spend in the direct sunlight most days?(Required) Have you ever had:(Required) Please choose all that apply
Measles/Rubeola Mumps Chicken Pox Whooping Cough Rubella Malaria Tuberculosis Shingles Meningitis None of the above
Do you enjoy eating?(Required) Yes No Eating is a big source of stress for me If I didn't have to eat, I wouldn't Eating is a source of pleasure for me Eating is a source of shame for me
How much water do you drink daily?(Required) Do you drink caffeine?(Required) Do you have an exercise, or movement practice?(Required) When it comes to secrets:(Required) Choose all that apply
I am an open book, I have no secrets. I keep a lot of secrets. I hate when people keep secrets from me. I feel like everyone I know is keeping secrets from me. Secrets are harmful. Secrets are good. Secrets protect me. If people find out about my secrets it will be dangerous. I don't trust people who keep secrets. I want someone to share my secrets with, but I don't feel safe. Sometimes I keep secrets.
What best describes your ability to concentrate/focus?(Required) Choose all that apply
I am always sharp and able to focus. I am mostly cloudy and sometimes sharp. I am mostly sharp and sometimes cloudy. I am sharp and rarely distracted I am sharp and easily distracted. I am always cloudy and unable to focus.
How would you describe your DAILY stress levels?(Required) Choose all that apply
My life is easy, I have no stress. I have light stress I am stressed most of the day; I can manage my stress well. I am stressed most of the day; I have a hard time managing my stress. I am so stressed that it's hard for me to function. I am in panic mode all of the time.
Most of my stress comes from:(Required) Choose all that apply
My work/career/job. My family. My romantic relationship(s). My children Money. Food. My appearance. What other people think about me. What other people say about me. What I think about other people. My emotions. Other
Do you smoke cigarettes/cigars/vapes?(Required) Do you drink alcohol?(Required) I do not drink Socially Occasionally Habitually (3-5 times per week) I consider myself an alcoholic
Have you ever been admitted to a rehab or detox facility for alcohol or substance use?(Required) Please check any of the following substances that you have experienced one or more times in your life.(Required) I do NOT share this information with ANYONE Ayahuasca Wachuma/San Pedro Magic Mushrooms/Psilocybin LSD/"Acid" Iboga/Ibogaine MDMA/Molly/Ecstasy Sassafras/Sass/MDA Marijuana/Weed/Cannabis Peyote Ketamine DMT 5 MEO DMT Kambo Bufo Kanna Speed Crack Cocaine NONE
Have you ever had a "bad trip"?(Required) Have you been exposed to crop dusting?(Required) Have you ever had prolonged exposure to lead or did you eat lead paint as a child?(Required) Have you ever had prolonged exposure to asbestos?(Required) Do you have any tattoos?(Required) Please check all that apply
I do not have any tattoos I am happy with ALL of my tattoos I regret my tattoos My tattoos are a source of stress I got my tattoos because I wanted to I love some of my tattoos and hate some of my tattoos
Have you ever trained in Martial Arts or Fighting Sports?(Required) Please check all that apply
been in a Fire been in a flood been in a monsoon been in a typhoon been in a tornado been in an earthquake been in a motorcycle crash been in an automobile crash fallen off a roof, ladder or height above 6 feet or 2 meters nearly drowned had to be revived by CPR been tied up against your will been held down or immobilized against your will been locked in a small space against your will been buried alive been trapped in an elevator been shot at or shot by a gun been stabbed at or stabbed with a knife or other sharp object been assaulted or hit with a blunt object such as a stick or bat been "jumped" or attacked by multiple people been hit with fists been kicked been spanked with a belt or other object been spanked by hand been slapped with an open hand been attacked by a dog, cat, bird or animal of any kind been sexually assaulted or raped been touched in a sexual manner without your permission been kidnapped been choked by another person been robbed at gun or knife point had your home broken into had your identity stolen had your car stolen or broken into witnessed anyone else be beaten up or jumped witnessed someone die seen a dead body witnessed an animal or insect die that disturbed you killed an animal hunting killed an animal not hunting killed a person in self defense witnessed a suicide known anyone that committed suicide witnessed another person be sexually assaulted seen anyone lose a limb or body part witnessed another person be shot or stabbed None
Have you ever been in a gang?(Required) Please check all that apply
Have you ever experienced any of the following?(Required) Please check all that apply
Kung-Fu Judo Mixed Martial Arts Boxing Taekwondo Krav Maga Wrestling Karate Aikido None
How often do you travel farther than 120 miles outside of your hometown/city?(Required) Please check all that apply
I never travel. Once per year. Twice per year. Four times per year. I travel more than I can count. I only travel if it is absolutely necessary. I travel for work. I travel for fun. I love to travel. I hate to travel.
Do you know what kind of birthing experience your biological mother had with you?(Required) Was your biological mother experiencing any trauma in her life from conception through her pregnancy with you?(Required) Are your biological parents alive?(Required) Mother, yes Mother, no Father, yes Father no
Do you have any siblings?(Required) Do you have any children?(Required) Do any of your children relate as being other than heterosexual?(Required) Do any of your children have any physical, mental, or emotional needs that require extra care?(Required)
How much time (in hours) would you say you spend alone each day?(Required) Not including sleep
Do any of your children have any physical, mental, or emotional needs that require extra care?(Required) Please describe for each child.
What time of day do you function best?(Required) I am a morning person I am a mid-day person I am an afternoon person I am an evening person I am a night person I am a late night person I am always functional Other
Which best describes your daily amount of sleep?(Required) Do you normally feel well rested when you wake up?(Required) Do you look forward to sleep?(Required) Have you ever experienced Sleep Paralysis?(Required) Do you experience recurring dreams or nightmares?(Required) Choose all that apply
I have never experienced recurring dreams of any sort I currently have recurring dreams I currently have recurring nightmares I used to have recurring dreams but not anymore I used to have recurring nightmares but not anymore
How do you relate with money?(Required) Choose all that apply
I love money I hate money I don't have enough money I have too much money I don't know the skill of money Money causes me a great deal of stress Money is easy for me I want to learn more about money I don't want to ever talk about money Money makes me anxious Money makes me angry I never look at my bank account unless I have to I am obsessed with checking my bank account
Please describe your current personal yearly income, in the currency you earn.*(Required) Choose all that apply
What’s Your ACE Score? And Your Resilience Score? The CDC’s Adverse Childhood Experiences Study (ACE Study) uncovered a stunning link between childhood trauma and the chronic diseases people develop as adults, as well as social and emotional problems. This includes heart disease, lung cancer, diabetes and many autoimmune diseases, as well as depression, violence, being a victim of violence, and suicide.
For this part of the questionnaire I want you to keep track of how many "YES" answers you have out of 10 questions, you will be asked to enter the total 0-10.
Prior to your 18th birthday: Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?(Required) Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?(Required) Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?(Required) Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?(Required) Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?(Required) Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?(Required) Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?(Required) Was a household member depressed or mentally ill, or did a household member attempt suicide?(Required) Did a household member go to prison?(Required) What’s Your Resilience Score? Please select the most accurate answer under each statement:
I believe that my mother loved me when I was little(Required) When I was little, other people helped my mother and father take care of me and they seemed to love me.(Required) I’ve heard that when I was an infant someone in my family enjoyed playing with me, and I enjoyed it, too.(Required) When I was a child, there were relatives in my family who made me feel better if I was sad or worried.(Required) When I was a child, neighbors or my friends’ parents seemed to like me.(Required) When I was a child, teachers, coaches, youth leaders or ministers were there to help me.(Required) Someone in my family cared about how I was doing in school.(Required) My family, neighbors and friends talked often about making our lives better.(Required) We had rules in our house and were expected to keep them.(Required) When I felt really bad, I could almost always find someone I trusted to talk to.(Required) As a youth, people noticed that I was capable and could get things done.(Required) I was independent and a go-getter.(Required) I believed that life is what you make it.(Required)
Your Info Name First Last
Emergency Contact Name First Last
Signature(Required) By signing this form you agree that you have answered all of the above questions honestly and to the best of your knowledge and ability. You also agree that you are submitting this information for use by The Emerging Soul solely for the purposes of supporting you in your work directly with them on your self-development. This information will not be shared nor sold to any other parties.
