Group Immersive Screening Application
This is part of the application process.We use this to get a sense of fit and readiness for the group experience.Take your time and answer honestly. Brief responses are completely fine.
Name
First Name
Last Name
Email
example@example.com
SECTION 1: Why Now
What's bringing you to this experience right now?
What feels most challenging or stuck in your life at the moment?
SECTION 2: Self-Awareness
What patterns do you notice in yourself that feel hard to shift?(e.g. overthinking, pushing through, shutting down, people-pleasing)
When something feels overwhelming or uncomfortable, what do you usually do?
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When something difficult comes up, how easy or hard is it for you to stay present with it?
SECTION 3: Group Fit
How do you typically show up in group settings?
What tends to make group experiences easier or more difficult for you?
SECTION 4: Support + Stability
Are you currently receiving any form of support? (therapy, coaching, medical, etc.)
Yes
No
If yes, how consistent or active does that support feel right now?
SECTION 5: Current Experience
In the past 3-6 months, have you experienced any of the following in a way that is still actively impacting you?
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(Check any that apply)
Thoughts about harming yourself (suicidal thoughts or ideation)
A suicide attempt or self-harm behavior
Significant depression affecting daily functioning
Panic attacks or persistent high anxiety
Trauma-related symptoms (e.g. flashbacks, dissociation)
Recent major life transition or loss
Periods of feeling emotionally overwhelmed or unable to regulate
Changes in sleep, appetite, or energy that feel concerning
Current substance use that feels hard to manage
None of the above
If you checked any of the above, please share anything that would help us understand your current experience.
SECTION 6: Intentions + Readiness
What are you hoping to get out of this experience?
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Based on where you are right now, do you feel resourced enough to participate in a group experience that includes emotional and somatic work?
Yes
Unsure/ Would like to discuss
No
SECTION 7: Experience History
Any prior experience with:(Check any that apply)
Therapy
Parts work / IFS
Somatics
Breathwork
Psychedelics / plant medicine
What has felt supportive or effective for you in the past?
What has felt frustrating, overwhelming, or not helpful?
SECTION 8: Logistics
Are you able to attend all components of the 8-week container, includingprep, the June 22–23 immersive, and Saturday 9:30–10:30 AM integrationcalls?
Yes
No
Need to discuss
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CLOSING
We review each application with care to ensure the group feels aligned, supportive, and
well-held for everyone involved.
If anything suggests this may not be the right level of support, we will follow up directly to
discuss next steps.
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