Name
First Name
Last Name
Date of Birth
MM
DD
YYYY
Height
Weight
Resting Pulse
Do you wear an activity or sleep tracker?
Yes
No
Only sometimes
30-Day Average HRV
30-Day Average Respiratory Rate
30-Day Average Daily Steps
Do you have any previously diagnosed or treated physical health conditions?
Yes
No
Please provide details that may be relevant to your ability to participate in the physical activity portion of this program.
Do you have any previously diagnosed or treated mental health conditions?
Yes
No
Please provide any details that may be relevant to your experience and participation in this program.
In the last 12 months, have you experienced any other notable physical, mental, or emotional symptoms (including mild-severe anxiety, depression, sleeplessness, brain fog, etc.)?
Please share your history of trauma from childhood to your adult life, including abuse of any kind (physical, emotional, or sexual), assault of any kind, car accidents, and any experiences of intense loss, fear, shame, or guilt.
Are you currently taking any medications?
Yes
No
If you answered yes to the question above, please list your medications here.
What are three specific outcomes you are looking to achieve in this mentorship?
In your opinion, what have been the biggest obstacles to you achieving these objectives in the past?
Have you ever used psychedelics or plant medicines (e.g. “magic mushrooms”)?
In some cases, these substances used in even sub-perceptible doses can ease and accelerate personal transformation. If determined useful for your situation, would you like to be informed?
Yes
No
Today, do you feel emotionally prepared to create whatever space is necessary in your mind and physical reality to achieve your goals?
Yes
No
If you find yourself in need of support at any time throughout this program, who could you call for support, and what is their relationship to you?
This mentorship is about personal exploration and growth, which can be incredibly rewarding and also very challenging at times. We recommend letting these people know in advance that you may need to lean on them for support.
Please describe your typical daily diet or nutritional approach.
Please describe your current movement or exercise regimen.
Please describe any current contemplative or spiritual disciplines you practice regularly.
Is there anything else Joseph should know about you before you begin this mentorship?
