Name

Age

Phone Number

Email Address

Mailing Address

List your employer and the type of work you do:

Are you currently or have you ever been under the care of a therapist, psychologist, or psychiatrist? If yes, please explain.

What types of personal and spiritual growth are you doing or have you done? Please explain

Please briefly describe your religious background, upbringing, experiences and current spiritual beliefs:

Do you have any history as the victim or perpetrator of violence? If yes, please explain:

Have you ever experienced flashbacks or extreme fear about physical touch? Do you have memories of physical, sexual or ritual abuse? If yes, please explain.

Have you or anyone in your family ever been suicidal? If yes, please explain:

Do you have any physical injuries or limitations? If yes, please explain.

Please Select If Applicable Please Select If Applicable Are you trained in any martial arts? Have you been diagnosed with PTSD? Have you served in the military?

What are your addictions- what have you been addicted to in the past?

What would you like to get out of your participation in this Shadow Work® Weekend?

What concerns do you have about your participation in the Shadow Work® Weekend?

Are you currently in a “mate” relationship and do you have children?

New Field New Field By Clicking The Box You Agree to The Cancellation Policy and Agreement: Please understand that we have a very limited number of spaces in this weekend, and we are counting on everyone who enrolls to attend for the whole weekend. This is important for the support of the container and the people who are there. Because of this, there are NO REFUNDS for your enrollment in this Shadow Work® weekend. Please be SURE that you can attend this entire Shadow Work® weekend before registering.

By Clicking The Box You Agree That I also understand that because of the limited time in the workshop, a limited number of participants will do a “center work” piece. There is much value to be gained from the workshop whether or not you do a center work piece. Please have a conversation with Jeannie or Mark about your registration and desire to do a center work piece. I also understand that Mark and Jeannie Daly-Gunter are not licensed psychotherapists and that they are certified Shadow Work® facilitators and coaches. I agree to have available any outside professional therapeutic support that I might need either during or after the weekend to help me integrate and process any emotional content that might arise for me.

I Agree To The Above (Name)

Date Agreed To Terms