SACRED FAMILY CEREMONY Questionnaire Form
Thank you for taking the time to answer these questions.
Name
First Name
Last Name
1. What are your personal intentions and goals for participating in this Family Medicine Ceremony?
*
2. Are you fully committed to participating in the entire ceremony, regardless of the challenges that may arise?
*
Yes
No
3. Are you willing to listen to each member's perspectives with the intention of fully understanding their views, emotions, expressions, and desires?
*
Yes
No
4. Are you willing to speak your truth, express your emotions, perceptions, and desires for the wellbeing dynamics of the family and for yourself?
*
Yes
No
5. Are you fully aware of the depth and intensity of the work you are about to undertake in this ceremony?
*
Yes
No
6. Have you discussed with each member of your family and agreed upon the importance of mutual respect, openness, and vulnerability during the ceremony?
*
Yes
No
We have not discussed or agreed but we are all willing to be in ceremony together to enhance our family dynamic & create a more harmonious connection with each.
7. Are you emotionally ready to confront any unresolved issues or past traumas that may surface during the ceremony?
*
Yes
No
I am not sure if I am emotionally ready to confront, but I am open to the opportunity to grow inward and with my family.
8. Are you committed to using the insights gained from the ceremony to heal, enhance, and improve your relationship with your family?
*
Yes
No
9. How do you plan to support each other emotionally throughout the ceremony and beyond?
*
I will be open to listen with the intention of understanding their perceptions, believes, views and desires
I am going to pay attention to my own words, body language, and attitudes that may have a negative imprint and correct my reactions towards each member of the family
I will do my sincere very best to be part of the solution and not the problem.
All of the above!
10. How would you describe your family's current level of Good Vive Energy ?
*
very low
neutrall
Very high
11. What would you say are the family issues today?
*
Lack of connection & understanding
Toxic environment
Unsafe home, no support
Past hurts and resentments
Money issues
Other
12. What is the family biggest strengths or values?
*
Mutual understanding & respect
Loving environment
Safe & supportive home
We all ready and like to evolve from our own human limitations
Other
13. What are the changes you will like to see in your Family?
*
More maturity and emotional intelligence in dealing with disagreements
Freedom to live life without shame, judgement, manipulation, or expectations
Harmony, peace and fun times together
Mutual respect and understanding
Other
14. Please rank what you consider is important to you in your Family relationship?
Rows
1 - Not Important
2 -little important
3 - Maybe
4 - Important
5 - Very Important
Deep healthy Connection (in Communication)
Security (feeling safe)
Harmony, peace & fun times together as a family
Responsibilities shared, everyone give & take
Healthy Emotional Expression
Financial stability
Being trusted & understood
Space to be myself without judgement
Spiritual Connection Family & individually
Felling of being heard & acknowledge
Feeling appreciated
Feeling accepted & loved
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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