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Vitalist Program
7-Week Guided Vitality Program
Experience your full power, adaptability, and creative expression.
First Name
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Last Name
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Email
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Phone
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Tell me about you.
What initially drew you to explore this transformational journey?
Briefly describe your relationship with spirituality.
On a scale of 1-10, how satisfied do you currently feel with your vitality and energy levels?
On a scale of 1-10, how satisfied do you currently feel with your vitality and energy levels?
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On a scale of 1-10, how committed to your overall well-being do you feel you are?
On a scale of 1-10, how committed to your overall well-being do you feel you are?
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What would becoming your most vital self make possible in your life? Take your time with this one.
Which areas of your life would you most like to experience transformation?
Which areas of your life would you most like to experience transformation?
Physical
Emotional
Mental
Spiritual
Relational
Creative Expression
Inspiration
Are you currently experiencing any physical tension, stress, or trauma that you'd like to address?
Have you worked with plant medicine or psychedelics before?
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If yes, please share some of your experience
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What practices or modalities have you explored in the past for personal growth? What resonated most with you?
Do you have any health concerns regarding this kind of work?
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Do you have any current or past medical conditions?(e.g., heart disease, hypertension, diabetes, epilepsy, or respiratory issues)
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Are you currently taking any medications, including prescription drugs, over-the-counter medications, or supplements?(If yes, please list them, including dosage and frequency.)
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Do you have a history of mental health conditions? If yes, please provide details and any current treatments.(depression, anxiety, PTSD, bipolar disorder, schizophrenia, or other diagnoses)
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Have you ever experienced a psychotic episode or been hospitalized for mental health reasons? If yes, please describe.
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Are you currently under the care of a therapist, psychiatrist, or other mental health professional? If yes, have you discussed your participation in a Huachuma ceremony with them?
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Do you have any history of substance abuse or addiction? If yes, please provide details and current status.
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How do you best receive support on your journey?
How do you best receive support on your journey?
1-on-1
Guidance
Coaching
Experiential Practices
Body Work
Breath Work
Meditation
Yoga
Other
What excites you most about the possibility of transforming your relationship to vitality, self, and source?
What aspects of nature bring you the most peace or inspiration?
Are there any particular patterns or blocks you've noticed that keep you from feeling fully alive and expressed?
What would it mean to you to feel creative, powerful, adaptable and in alignment with your deepest values?
How ready do you feel to commit to a 7-week journey of deep transformation?
Is there anything specific you'd like to know about the program or process?
What support systems do you currently have in place for your well-being journey?
When you envision your most vital self, what does that look and feel like?
Thank you!
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