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.

🩵 Section 1: Contact Information
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.

🌿 Section 2: Intensive Details
Which 5-day immersive experience are you most inclined to attend?*

April 26–30, 2026, Yachats, Oregon (Oregon Coast)September 14-19, 2026, Culver, Oregon (Central Oregon)Other
How did you hear about the Rooted HEART Intensive?*
If referred, please share who referred you:

💫 Section 4: Personal Readiness & Intention
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?*

YESNO
If yes, please please describe:
Are you comfortable engaging in guided imagery, gentle movement, and group reflection?*

YESNOUnsure (let’s talk during our call)
Is there anything else you’d like your facilitators to know to help you feel safe and supported?

🌼 Section 5: Consent and Acknowledgement
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

Clear
Date of Birth

MonthDayYear
Date
Should be Empty:

Rooted HEART Resilience Intensive