Somatic Healing Group Application Form
Please answer all questions to the best of your ability
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Name *
Date *
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Email *
Phone # *
Address *
Age *
Gender Identity/Pronouns *
What is your occupation and/or artistic practice? *

I am seeking body/mind group process at this time because:

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I am aspiring towards these developments and/or experiences:
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Please describe any known physical limitations or restrictions:
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Briefly describe any use of substances/activities you may be utilizing on a daily or weekly basis to alter or regulate thoughts and feelings (including, but not limited to: substances, sugar, sex, exercising, gambling, shopping, TV, eating:
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Please describe any history of mental illness, hospitalizations for mental illness, or suicidal ideations:
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Briefly describe any history of or current mental health treatment/counseling (therapy, etc.):
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Are you on any medication?
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If yes, please list what medication(s) you are currently taking: 
What are your relationships like?
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What kind of emotional support do you currently have?
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Please describe any major trauma or losses that you think it is important for me to know about:
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Where is your life in flow? What brings pleasure in your life?
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Where do you feel stuck? What’s difficult?
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What is it you would like me to know about you? Give me a sense of your essence?
I agree to attend at least 8 out of the 10 sessions.
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I agree to be on time for all sessions.
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I agree to a commitment of privacy (what happens in the room stays in the room).
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How did you hear about this opportunity? *
Please confirm that you have paid for the program below. Registration is open until this form is closed, so you will not be denied from the program once you have submitted the form and paid. *
Pay Registration Fee:  

-Remember that your registration fee is due at the time of submission. 
-To pay, you may use Zelle. 
-For other payment options please inquire. 
-Once you have paid the fee, remember to return to this form and press the submit button. 
-After payment we will confirm and contact you for a 15 minute zoom introduction on the program. 

Early Bird Discount: No longer Available

After September 1, 2025
Zelle: $450 direct to VGreen@DanceEntropy.org

**NO REFUNDS AFTER SUBMISSION**

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