HEART Participant Screening-Connection Form

Rooted HEART Resilience Intensive

Participant Screening & Connection Form
Thank you for your interest in the Rooted HEART Resilience Intensive — a trauma-informed, experiential immersion designed to support emotional resilience, self-awareness, and renewal. To ensure a safe and supportive space for everyone, we ask that you complete this confidential screening form before registering.

After we receive your responses, you’ll receive a link to schedule a brief 15–20 minute Connection Call with a faculty member. This call helps us ensure the timing and experience are right for you and allows you to ask any questions before enrolling.
- Please Note. We Value Your Privacy.
  
  (All information is confidential and reviewed by faculty before enrollment.)
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Which 5-day immersive experience are you most inclined to attend?
  
  Other
- How did you hear about the Rooted HEART Intensive?
- If referred, please share who referred you:
- Please Note. We Value Your Wellbeing.
  
  This information helps us hold a safe and supportive space. It is confidential and will only be reviewed by faculty.
- Are you currently under the care of a physician or therapist?
- If yes, please share the general nature (no details needed):
- Do you have any chronic medical conditions or recent injuries?
- If yes, please share the general nature (no details needed):
- Are you currently taking prescribed medications?
- If yes, please list general categories (e.g., antidepressant, blood pressure, etc.):
- Do you have any allergies or dietary restrictions?
- Have you ever been diagnosed with or currently experience any of the following?
  
  Other
- Are you currently in crisis or have you been recently hospitalized for mental health reasons? (If yes, a brief conversation will help determine readiness and support options.)
- What is calling you to participate in this immersive experience?
- What areas of growth or healing are you currently seeking?
- Do you currently have a self-care or mindfulness practice?
- If yes, please please describe:
- Are you comfortable engaging in guided imagery, gentle movement, and group reflection?
- Is there anything else you’d like your facilitators to know to help you feel safe and supported?
- I understand that the Rooted HEART Resilience Intensive is an educational and experiential program designed for personal and professional growth.
  
  It is not psychotherapy or medical treatment.
  
  I affirm that the information provided above is accurate to the best of my knowledge.
- Signature
- Date of Birth
  
  MonthDayYear
  Date
- Should be Empty:

Rooted HEART Resilience Intensive

Please Note. We Value Your Privacy.

Please Note. We Value Your Wellbeing.