Intake form Resiliency - Inspiring Mountains

Intake Form EJC Resiliency Training

As part of the intake process you are kindly asked to truthfully complete this form. The answers you provide to the questions below, together with a short orientation interview on Zoom, are intended to gather relevant background information about your current health and needs in order to ensure that your expectations are met and that this training is a right fit for you.

All information provided by you in this form is regarded as private and used only by the Inspiring Mountain trainers delivering this training. The information provided is not shared with anyone else other than the trainers.

Name

Gender

Country of birth

Date of birth (dd-mm-yyyy)

Phone number

E-mail address

Address

City

Postal code

Country

Profession (Organization / function)

1. Can you say something about your reason for participating?

2. What do you expect to learn in this training?

E.g.: What is causing you the most stress at the moment that you would like to learn to deal with?

3. Do you have any physical limitations that might affect or restrict your participation? (if so please clarify)

4. Do you have any meditation experience, if so, please describe which form and how often and how long you meditate?

5. Which of the following statements are true for you?

N/A

You often put your work above your own well-being.

You pressure yourself to create greater impacts than your project or organizational budgets enable you to achieve.

You experience increased stress due to the political, social, and psychological pressures and threats that come with your work.

You are often anxious because you operate in an environment of uncertainty, scarcity, and dependency.

You are frustrated by the lack of autonomy, the unrealistic number of tasks and responsibilities you have due to the counterproductive culture in your organization.

You are discouraged by the frequent shifts in priorities and unclear strategies within your organization.

You struggle to create or sustain a healthy separation and balance between work and life.

It is difficult for you to set and maintain boundaries with yourself and others.

Other (please clarify)

6. Are you currently experiencing any of the following psychological symptoms? (Please tick the appropriate box(es))

N/A

Restlessness

Uncertainty

Anxiety/Panic

Burnout

Highly self-critical

Sadness

Feeling emotionally unbalanced

Rumination/Worry

Depression

Suicidal thoughts

Other (please clarify)

7. Are you being supported by a practitioner (trauma-therapist, psychologist, psychiatrist or coach)? (Please clarify.)

8. Add any other information, comments or questions that you think are relevant to share?

I would like to subscribe to the newsletter

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