Confidential Intake Form

LifeApp | 3 Day Confidential Intake Form
Your General Information
Full Name

First NameLast Name
Name Tag
Your Preferred First Name
Pronouns
I.e. She/Her He/Him They/Them etc.
Date of Birth

MonthDayYear
Email

Confirmation Email
Phone Number

Country CodeArea CodePhone Number
Occupation
Select the 3 Day retreat dates you would like to attend.
Current and Childhood Photo

Please upload a current face shot and a good quality digitized photo of yourself as a child (from 3 - 10 yrs old). Below are some examples of the kind of photos we're looking for.
UPLOAD PHOTOS: 1. Current face shot. 2. You as a child (3-10).

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Your Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Format: (000) 000-0000.

Lets Go A Little Deeper!
What do you want more of in your life?
What would you like to gain from this self-discovery retreat?
If you gain that, how will your life be different?
What is the most important thing in your life that you are proud of?
What is the accomplishment in your life you are most proud of?
Describe your level of anger with yourself.
Describe your level of anger with others.
Tell about the happiest time in your life.
Tell about the greatest challenge in your life.
What has hurt you most in your life?
Describe your childhood.
What is your greatest fear?
What would someone who knows you well say your strengths are?
What would they identify as your weaknesses?
Describe the quality of your life?
Describe the quality of your relationships?
Home, Family, Work, Friends, Others
Is your life currently better or worse than it used to be?
Why is it better?
Why is it worse?

Your Mental And Physical Well-Being

We want to be sure that the 3 Day is going to be compatible with where you are at and what you need, so that you have a positive experience and gain the most value you can from this program.
Have you ever attended counselling? If so, how recent, for what reason, and was it helpful?
Have you ever had a mental health diagnoses ie: anxiety, depression, PTSD: If so, date, physician, medication prescribed.
Do you have a history of trauma? If so, when did it happen, what happened, and how has it been treated?
Trauma is the lasting emotional response that can result from living through a distressing event. A traumatic event could include: a recent, single traumatic event (e.g., car crash, violent assault) a single traumatic event that occurred in the past (e.g., a sexual assault, the death of a spouse or child, an accident, living through a natural disaster or a war) a long-term, chronic pattern (e.g., ongoing childhood neglect, sexual, physical, or verbal abuse). Dig deep and ask yourself, what are you pretending not to know?
Do you have a history of addiction? If so, are you in an active state of addiction? Please identify the addiction. If resolved, when and how?
Have you ever been in Foster Care, Residential School, Mental Health Facility, or prison?
At what age ie: 9 - 19, when 1998-2005
Have you ever been suicidal? If so, please share any information that may be helpful.
Are you currently before the courts on any charges, including Family Court?
All meals and snacks provided on retreat will be vegetarian. Are there any serious food allergies we should be aware of?
e.g. foods such as peanuts, tree nuts, seafood, wheat, milk, or eggs etc. that could cause anaphylactic shock.
Are there any medical conditions we should be aware of?
ie: diabetes, epilepsy, high blood pressure, special medications etc. Important Note: The 3 Day Medical Team will only access the medical information above, not the rest of the intake form.

Let's Make Sure We're On The Same Page!
I have read, understand, and am willing to commit to the following
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LifeApp | 3 Day Confidential Intake Form