Soul Imprints ~ Family Constellations

Soul Imprints ~ Family Constellations

Where the soul makes movement towards being whole again
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I am willing to attend the Family Constellation workshop as:
What is your previous experience with Family Constellations?
Do you have any previous mental health history &/or diagnosis? Any information you offer here is strictly confidential and designed to help me best support you *If yes, please describe i.e. anxiety, depression, panic attacks etc
I consent to being photographed &/or recorded, during the workshop. This may be used for advertising purposes, including but not limited to Facebook.
Please tick to show your understanding and consent to the following 7 statements
1. I agree to respect the privacy of all participants

2. I agree to treat everyone with respect, even if I don't agree with the topics that may be raised during the workshop

3. I understand that Family Constellations can not diagnose, fix or heal any ailments or health conditions and does not make this claim

4. I agree that I will speak to the facilitator if I am feeling triggered and/or need extra support, during the workshop, or after

5. I have a support network outside the workshop, should I feel I need it, such as friends, family and/or professional support worker

6. I have disclosed all relevant health information regarding my current health condition including but not limited to... blood pressure, mental health, physical health etc

7. Yes, I am ready for a big shift!
I agree that I am over the age of 18 years
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Signature
Thank you for completing this form ~ Amba Parker ~ 0411 300 652
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