Grieve & Glow Group Program Survey

Hello, love! YOU MADE IT! Celebrating you for being here! Please take some time to answer the following questions to the best of your ability. I can’t wait to connect with you!!

Name

First Name

Last Name

Pronouns

Phone

(###)

###

####

What are you grieving?

What are your biggest challenges in life right now?

Tell me about who you would like to be at the end of this program. What kind of a person do you want to become?

What is your relationship with your body like? With your pussy? (if you don't identify with the word ‘pussy’, then the energy of your genitals)

What other modalities or practices have you interacted with to help you reach your goals? Do you have a daily practice?

If you have undergone therapeutic treatment for any of the following: bi-polar/manic depression; post-traumatic stress; clinical depression; eating disorders; and/or suicide attempts, please share any details you'd like for me to be aware of below.

I stand in solidarity with all people from marginalized communities and work with clients who do as well. Are you doing anti-racism, LGBTQI+ or other diversity and inclusion work to expand your learning, overcome bias, understand privilege and advocate for these communities?

Are you on board to help make this a safe and confidential space for all womxn?

What can I do to help make you feel comfortable during this program?

How did you hear about this program?

Why did you join this program?

Is there anything else you would like me to know?

Did anyone refer you? (If yes, Who?)

Is there anything else you'd like to share?

Grieve & Glow Group Program Survey

Sara Chizek