Pathways to Renewal 6-Week Follow Up
Please complete this form to help us understand the continued impact of our program(s). Please note, this information will be kept confidential between you and Anahata Wellness Society, with the exception of the indication of harm to self and/or another.
Personal Information
Full Name
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First Name
Last Name
Preferred Name
Which tools or practices are you still using?
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How often are you using them?
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What difference, if any, are they making?
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What has made continued use difficult?
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Confidentiality & Consent
I understand that my information is confidential, and will only be used to support my participation in Anahata Wellness Society programs. I may withdraw at any time. Please type your full name and the date below:
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Signature
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Thank you for taking the time to fill this out. We are deeply at your service. - Anahata Wellness Society
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