Please complete and submit this application.
First Name*
Last Name*
Email*
Phone*
Reasons, Hopes, Expectations for taking this class?
DO YOU EXPERIENCE CHALLENGES WITH: Autism Spectrum Disorder, Addictions, Panic attacks, Generalized Anxiety Disorder, Social Anxiety, Obsessive Compulsive Disorder, Post Traumatic Stress Disorder, Bipolar Mood Disorder, Borderline Personality Disorder, Suicidal Ideation, Self-Harming Behaviours, Depression. Please specify and for how long?
HAVE YOU BEEN FORMALLY DIAGNOSED BY A PSYCHIATRIST? YES/NO
ARE YOU CURRENTLY OR HAVE YOU BEEN IN COUNSELLING? YES/NO
ARE YOU CURRENTLY ON ANY MEDICATION? PLEASE LIST:
ARE YOU SUFFERING FROM ANY CHRONIC PHYSICAL PAIN CONDITION that prevents you from either working, going up stairs, lying down on the floor, sitting for long periods. Please list the details.