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Questionnaire
Welcome to the questionnaire, please take time to think about the questions
and be as transparent as possible. We use this information to assess if and
how we can better help you.
Some questions may seem silly but just go with it ; ).
First Name
Email Address
Last Name
Phone Number
Please list any Medical/ Psychological Conditions (all information kept confidential)
Are you taking any pharmaceutical medication? Or have you in the last few months stopped taking a pharmaceutical medication? Please name the medications, what condition they are prescribed for, the dose that you are taking, the frequency and how long you have been taking them.
Do you or have you recently use(d) Recreational substances? If yes, please give detail of what and time frame(s). When was your last usage?
In your own words, what is your intention for this journey?
Which of these colours do you like the most?
Choose an option
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Which of these colours do you like the least?
Choose an option
arrow&v
Which of these blockers apply to you?
Anger
Fear
Sadness
Guilt
Loneliness
Depression
Emptiness
Frustrations
Inadequacy
Helplessness
Resentment
Failure
Jealousy
Please tick if you agree
I understand that this program should not replace professional psychological therapy.
I take full responsibility for all of my actions, welfare and personal transformation whilst participating in this program and agree that it is my own choice to participate.
I am willing to commit to this process and take responsibility for myself within this work
I agree not to share personal information regarding any other participants within the circle. ie Names
I agree to receive relevant communication from Sacred Unveiling regarding classes and events.
I declare that I have accurately and truthfully answered all the above questions and have given necessary information regarding my physical health, emotional wellbeing, recreational activities and medications: and have not withheld any information that I believe could be important.
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