An Invitation to Healing - Program Application
This form does not allow you to save your progress, so we recommend completing in one sitting or writing your answers in a word document and pasting them into this form below. For a complete list of questions, see link above.
Email *
Please list date(s) of 6-week online program you are interested in attending. *
Upcoming Program Dates: September 14th - October 21st, 2021
First Name *
Last Name *
Cell Phone Number *
Home Phone Number
Zip Code
Occupation or brief work history
I am currently working:
Clear selection
Current marital status:
Clear selection
Ages of children (if any):
Are you presently under the care of an oncologist?
Clear selection
Please provide the name of your Oncologist or primary medical doctor.
Please provide the phone number(s) for your Oncologist or primary medical doctor.
Approximate date of initial diagnosis:
Please provide your cancer diagnosis (including type of cancer and stage, if known):
Do you have any metastases? (If yes, please be specific.)
Have you had a recurrence?
Clear selection
If yes, when?
Are you currently receiving treatment for your cancer?
Clear selection
If yes, do you feel this will affect your ability to participate?
Clear selection
Are you currently taking medication for pain, depression or other conditions?
Clear selection
If yes, please describe:
What is your current height in feet and inches?
What is your current weight in pounds?
What types, if any, complementary/adjunctive therapies have you used in the past or are you currently using?
Please list the current areas of greatest stress in your life presently (e.g., cancer therapy, relationships, work, finances, etc.):
Are you currently seeing a psychiatrist, psychologist or other counselor?
Clear selection
If yes, please indicate your start date and any diagnosis received (if applicable):
What has been the hardest part of your cancer journey?
What are the major sources of support or nurture in your life?
Do you currently feel that this level of support is sufficient?
Clear selection
How did you learn about the 6-week healing program?
What are your reasons for wanting to participate in the 6-week healing program?
Do you have any concerns or fears about participating in this program? If so, please explain.
Are you currently on a special kind of diet?
Clear selection
If yes, please describe:
Never submit passwords through Google Forms.
This form was created inside of Smith Center for Healing and the Arts. Report Abuse