EXPRESS YOUR INTEREST / REGISTER DETAILSSomatic & Expressive Grief Therapy Program Name * First Name Last Name Email * Phone * Country (###) ### #### Is it okay to leave a private voice message? * Yes No Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Female Male Other Prefer not to answer What is the best way to contact you? * Email Phone Call Text Date of Birth * MM DD YYYY What kind of loss have you experienced? (please select all that apply) * Spouse Child Parent Sibling Friend Grandparent Pet Other Are there any other losses you would like to disclose? (please select all that apply) Divorce Miscarriage Stillbirth Identity Job Relationship Other When did your loss occur? * MM DD YYYY How is your loss affecting you now? * Have you had more than one loss in the past 5 years? * Yes No Are you currently in counselling? * Yes No No, but I have had some counselling What is your current support system? * Have you experienced any events that you would consider traumatic, whether related to this loss or not? * Yes No If yes, please explain? Do you currently have any creative outlets for your grief? If so, what are they? Do you currently practice yoga? * Yes No No, but I have practiced yoga before Do you have any injuries or disabilities that will affect your practice? * Yes No If yes, please explain. Please tell us why you are interested in participating in the Somatic & Expressive Grief Therapy 12 Week Program? * Please select which Somatic & Expressive Grief Therapy Program you are interested in. * In Studio - Sunshine Coast Online - Zoom Video Is there anything else you would like for us to know? Thank you for expressing your interest in the Somatic & Expressive Grief Therapy Program, and my deepest condolences for your loss.We will review your completed form, and reach out to you shortly.Take care in the meantime, and be gentle with yourself…
