Intake Form

Please answer the following questions as completely as possible. Your answers will help our facilitators give you the best, most rewarding experience they can during this program.

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Name *

First

Last

Email *

How did you find out about our program? *

What is the main problem you are dealing with in life right now? *

What is your greatest fear? *

This is potentially a powerful, intense experience. You may be challenged in many ways. Are you ready for such an experience? If so, why? *

What are a few important sources of personal support in your life right now? *

What physical, mental, or emotional challenges may prevent you from full participation in the 4-week program? If so, please describe them.

What else about you should we know when engaging with you in this program? Relationship status, work status, life goals or dreams, family dynamics?

What is your definition of an ideal man? *

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