Group Participation Intake Form
  • Todays Date
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  • Group Participant Registration Form

    For all groups facilitated by the N'Spired Network of providers in partnership with N'Spired By Achievement Family Services & Solutions, LLC.
  • Date of Birth*
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  • What groups are you interested in participating in?
  • What times of day are more beneficial for you?
  • Which days work better for you?
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  • Program Information

  • Present Health

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  • Rows
  • Childhood illnesses:*

  • Immunizations/vaccinations:*

  • Daily Routine (dinacharya)

  • Do you get up early?
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  • Do you go to bed early?
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  • Do you sleep during the day?
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  • Bowel movement associated with (choose those that apply).*

  • Do you delay or suppress any of the following?
  • Do you travel often? *
  • Do you self-massage with oil daily?*

  • Excercise

  • Eating Habits

  • Rows

  • Describe what you typically eat

  • Do you eat between meals?*
  • Do you eat meals at regular times?*
  • Describe your diet.*

  • If you are a nonvegetarian, please indicate the proteins you eat.

  • What taste(s) do you like to crave?*
  • Are there particular foods that create discomfort when you eat them?*

  • Miscellaneous

  • Are you allergic to any substances?*

  • Do you experience any of the following?*

  • Social History

  • Rows
  • As a child, did you experience any abuse or trauma?*
  • Type of abuse:*

  • For Men Only

  • Please indicate which of the following areas are troublesome (if any).

  • For Women Only

  • How many days does your menstrual period last?

  • Do you have any associated symptoms (before or during menstruation?
  • Do you have any discharge outside of your menstrual period?
  • Do you ever experience pain during intercourse?
  • Are you pregnant now?
  • Do you have any sexual difficulties?
  • Do you take contraceptive pills or use other forms of birth control?
  • Do you breast self-exam regularly?
  • Do you experience any of the following?

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    I understand that this form is completed for the purpose of participation in an educational group (be it coaching or therapeutic) for the purpose of creating an online or in person community of support helping me improve my personal wellbeing, develop insight, and/or cope with changes in life. I understand this does not include medical diagnoses or treatment and is not a substitute for medical care, 1-on-1 mental health therapy or an agreement for ongoing care post group completion.

    I also understand that upon pressing submit, I may receive coorespondence regarding times available for the group as well as other recommendations deemed beneficial based on the information provided above.

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