Journey Application

Thank you for taking the time to answer these questions. Our intention is to understand your specific healing intentions so we can refer you to the most appropriate practitioner. This is a confidential record. * Please note this form will NOT save while you work on it! If you close this page and come back, your answers will not be saved. * If you have any questions, please email us directly at leah@thesovereigntyway.com

First Name

Last Name

Phone Number

What is your email?

Date of Birth

Where do you live?

What is your occupation?

Describe your business and what you do.

Who referred you to this work?

What is your intention for doing medicine work?

{name}

Medicine Work Experience: Are you experienced with medicine work in any form? If so, please describe which medicines.

{name}

Is there anything else about your personal life that is important for you to share? (Are you going through any personal transitions, health challenges etc.)

{name}

Mental Health History: If you have the symptoms below, please check the box. If you don't have symptoms, leave blank.

Do you have any current or past psychological or psychiatric conditions? If yes, please give the dates and describe the circumstances.

{name}

Please give a brief description of your trauma history.

{name}

Do you have a preference around work with a man or a woman?

{name}

Anything else you'd like us to know?

{name}

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