Body, Breath & Soul Questionnaire

 

Name *
Name
Address
Address
Do you have any chronic pain, physical limitations, or disabilities?
Are you taking any heavy medication? *
Do you have an active addiction?
Have you had a serious illness or major surgery within the last five years?
Have you experienced trauma, either physical or emotional, recently or in the past? *
Are you currently under medical treatment for any physical or mental conditions?
Are you currently experiencing an emotional or physical crisis? *
Are you currently pregnant or trying to get pregnant?
Do you currently have or have you had any of the following conditions in your lifetime: *
Please indicate other professionals you currently use:
Please indicate any of the following vehicles you use toward personal growth and development:

Instagram #love

Tennis for Clara and I, a good run (for Erick) and now some outdoor chess under a canopy of monkey pod trees. Springtime in #Zambia. #love #family #nature
Deep breath. Just so. Remembering #beauty this day.
#zambeziriver crayfish are one of my favorite foods— the evidence? A pile of skeletons with the meat picked out. Fancy finger food at #lilayilodge #withlovefromzambia
My beloved bought me a hand-carved drum from the side of the road near #lakekariba — his life will never be the same. #cantstopwontstop #love #zambia #letsdrum
Today, I’m writing about belonging when outside forces insist you don’t matter. The synopsis? Let me assure you: you matter. You belong. The very essence of you, the fullness of your being is absolutely necessary for the world we are creating. #love #beauty #truth #youmatter
Good morning, #beauty — fresh herbs (thyme, rosemary and lavender) for roasting chicken. The #joy it brings me to go out in the morning sun to pick herbs and then prepare the chicken? So good. AND the #Zambia #villagechicken is so tasty. #eatgoodfood #yum