Rooted weekend
Intake form for the Rooted group weekend at De Hoorneboeg
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Would you like to be part of the group weekend at De Hoorneboeg where we offer support in grounding, rooting and belonging?
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What is your name? *
What is your date of birth? *
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What is your gender? *
In which town/city do you currently live? *
What is your country of birth? *
What is/are your nationality/ies? *
In what language(s) can you comfortably express yourself? *
Required
Since what year do you live in The Netherlands? *
What does 'being rooted' mean to you? *
On a scale from 1 to 10, how 'rooted' do you currently feel?  *
Uprooted
Fully rooted
What makes you want to participate in this weekend? *
Do you have any dietary restrictions or wishes for the weekend?
What cooking ingredient reminds you most of your roots? *
Could you please provide us with your telephone number so that we may contact you? *
Could you please provide us with your e-mail address so that we may contact you?
 *
Do you have or did you have any physical or mental medical condition that we should be aware of?  *
We will reach out to you at the earliest convenience for an intake conversation. Your participation is not yet confirmed until after the intake conversation. We will jointly discuss if your expectations and desires align with what Rooted can offer. 

Do you have any other questions or comments for Rooted at this stage?
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