HIWMH Program Intake Form

Participant Enrolmet Form

(Holistic Integrated Wellness & Mental Health Program (HIWMHP)
Disclaimer and Acknowledgment

Please Read Carefully:

The Holistic Integrated Wellness & Mental Health Program (HIWMHP) is designed to provide educational, experiential, and practical tools to support overall well-being, personal growth, and holistic wellness. The program includes exercises and activities that encourage self-reflection, mindfulness, emotional awareness, and personal development.

Important Notice:

This program is not intended as a substitute for professional mental health care. It is not suitable for individuals currently experiencing serious mental health conditions such as severe depression, acute anxiety disorders, psychosis, or any condition that may be adversely affected by introspective or experiential exercises. Some practical activities may evoke emotional discomfort or distress. Participants are encouraged to consult a qualified mental health professional if they have concerns about their readiness for participation.

By enrolling in this program, you acknowledge and accept that:
1. You are voluntarily participating in the program and its activities.
2. The facilitators are not providing clinical therapy or professional mental health treatment.
3. You are responsible for monitoring your own emotional and physical well-being during the program.
4. You may discontinue participation at any time if you feel uncomfortable or distressed.
Please complete this form accurately and provide your signature below to confirm your understanding and agreement.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender / Preferred Pronouns*
Current Age*
Phone Number*
Email*
example@example.com
Address*

Building/Community Name

Street Address

CityState / Country

Postal / Pin Code
We’d love to know, how did you hear about this program?*
Do you have any allergies or current medications? (If yes, please list them)
Current Education Level / Profession: *
We’d love to get to know you! Please provide a brief introduction about yourself and share what inspired you to join this program.*
Emergency Contact

First NameLast Name
Phone Number
Payment Method*
Date of the Filling Form*

MonthDayYear
Date
Participant Signature*

Clear
Guardian Signature (if under age 18)

Clear
Consent & Confidentiality Agreement*

I consent to the collection and safe storage of my personal data for program purposes only.I hereby declare that the information provided above is true and accurate to the best of my knowledge.
Should be Empty:

Participant Enrolmet Form