🌿 4-Week Embodied Arts Healing Program Application

This questionnaire is designed to offer space for reflection on what you truly desire for your healing and self-expression journey. It also helps us determine if this program is an optimal fit to support your unique goals at this time. We look forward to hearing from you!

Full Name

Phone *

Email *

Date of birth

City

State

Social Media Handles (IG or FB)

How did you hear about the program?

🦋 Your Vision for Healing & Self-Expression

1. What do you truly desire for your life and healing? (Describe in as much detail as possible—what kind of emotional, creative, and personal freedom are you seeking?) *

2. If you could achieve 2-3 transformative changes in your healing and self-expression journey, what would they be? (Be specific about the breakthroughs you want to experience.) *

3. Why do you want this? (What deeper purpose or feeling is calling you to seek healing and creative self-expression?) *

4. What do you see as your biggest obstacles to having what you want? (Please list them below—whether internal (self-doubt, perfectionism, fear, etc.) or external (time, resources, environment, etc.) *

5. Why is now the right time for you to step into this journey? (What has changed in your life that makes this the moment to invest in yourself?) *

🌱 Readiness & Commitment

6. Have you explored somatic healing, movement, meditation, or expressive arts before? If so, what has been your experience? *

7. How ready do you feel to step into this journey—emotionally, energetically, and financially? *

8. What hesitations or concerns do you have about joining this program? *

9. What type of support do you feel would be most helpful for you? (e.g., structured guidance, gentle encouragement, deep exploration, community connection, etc.) *

10. Are you open to somatic facilitation, meditation, movement and creative expression as tools for healing? (Yes/No, and please share any concerns if applicable.) *

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