Pre Questionnaire

Share why are you interested in attending the retreat? What do you hope to gain?

What is your race/ethnicity? Your sexual orientation? Your relationship status?

Describe your immediate and past health history. Include any medications you take and why.

Share your routines with alcohol, cannnabis, recreational drugs, over-the counter/subscription drugs, or other altering substances of any kind.

Who should we call in the event of an emergency? List name, relationship and phone numbers.

Describe your family of origin; the family you grew up in (2-3 paragraphs max). Include where you grew up.

Describe the type of work you do (1-2 paragraphs max).

Share a story of childhood rage or fear. Where were you? What occurred? Who was there? How did you feel? How did you defend yourself? What were you ashamed of? What would you change about the situation? How do you feel about this situation today?

Share the emotional atmosphere you grew up in [in your family, in your community, in the world]: What feelings were the most common? Lease common? What was feared, celebrated, longed for, etc.? Overall, how would you characterize your childhood?

What patterns do you find yourself repeating that enrages you? Shames you? Share examples and include how you respond to them.

This may be a difficult question, but do what you can to answer it! What ancestor [known or through stories] does your rage resemble? Share a story of how you are similar/different to this ancestor. What did he/she leave unresolved?

What do you imagine your rage keeps you from experiencing, knowing, or doing?

Describe your support systems (currently and within the last 12 months). What services do/have you receive(d)? How often do/did you receive them? What routines do you practice for your well being?

What are you longing for? How long have you wanted it? What story does this longing represent?

What else would you like to share?