Connecting Hearts Participant Intake Form

Connecting Hearts Peer Support Program
Participant Intake Form
Name*
Address*
Phone Number*
Format: (000) 000-0000.
E mail Address*
example@example.com
Do you prefer to be contacted by text, phone call or email?*
Format: (000) 000-0000.
Current Diagnosis and Treatment
Support System
Self Care Practices
What are you looking for from a peer supporter?
What wellness services are you interested in? Check all that apply.

YogaReikiSupport groupCounselingSound HealingFacialsTai ChiMeditationCrystal HealingPolarity Therapy
What time of day are you most available ?*
What else would you like us to know about you and your life?
Should be Empty: