PERSONAL INFORMATION:
Full Name:____________________________________________________Pronouns:___________
Preferred Name:___________________________Birthdate:________________________________
Phone:__________________________ Email:__________________________________________
Mailing Address:__________________________________________________________________
EMERGENCY CONTACT INFORMATION:
Name:_______________________________________________________Pronouns:__________
Relationship to you:_______________________________________________________________
Phone:__________________________ Email:_________________________________________
HELP US GET TO KNOW YOU BETTER:
What can you contribute to The Tree of Life? What skills do you have?
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Do you engage in a regular spiritual practice? If so, explain:
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What does spirituality mean to you? ____________________________________________________________________________________________________________________________________________________________
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Are there any aspects of your mental and physical health that we should be aware of?
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What are your needs? Including social (ie. alone time in evening, morning mediation, cup of coffee in the morning etc.) and dietary needs?
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Anything else you would like to share with us?
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SIGNATURE:
Name:_____________________________________________________________________
Signature:__________________________________________________________________
Date:______________________________________________________________________
Looking forward to working with you!