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Medicine Session Intake
SECTION 1: Basic Information
Full Name
*
Date of Birth
*
What pronouns would you like us to use?
*
A
She/Her
B
He/Him
C
They/Them
D
She/They
E
He/They
F
Ze/Zir
G
Any pronouns
H
Ask first
What is your gender identity?
Please click any that apply.
*
Woman
Man
Nonbinary
Genderqueer
Gender Fluid
Two-Spirit
Agender
Transgender
Cis-gender (gender matches sex assigned at birth)
Prefer not to say
Email address
*
Phone number
*
Emergency contact name
*
Emergency contact phone
*
Are you interested in personal or group work?
*
A
1:1
B
Full dose group retreat
C
Low dose evening group
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