HEAL Program Intake

Date of Submission

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
HEAL Questionnaire
Your Name

First NameLast Name
Your Email
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Your Mobile Phone Number
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Welcome to your HEALing journey!

Our goal is to help you get from "here" to "there". In order to do that, we need to learn more about what "there" looks and feels like to you. This is a very personal question, and you may not have clear answers... yet. That's okay. Part of the healing process is stepping into a zone of inquiry and engage (sometimes wrestle) with these questions. This questionnaire is just the beginning of a process that will morph and grow over time.

A few suggestions:
- Put effort/time into answering the questions. This is definitely one of those "you get out what you put in" situations.
- It's okay if you don't have 'good' answers. Just sit with the questions and allow them to percolate. Do your best to answer from where you are in this moment.
- We want to learn about you so we can support you in ways that feel good to you. The more you share with us, the more we can roll up our sleeves and get good at helping you get to "there" quickly.
- You don't need to have all of the answers now. They will come as you immerse yourself in your process. Simply do your best right now.
We look forward to supporting you on your journey!

If you could wave a magic wand and change 3 things about your life overnight, what would they be? How would making these changes improve your life experience? Try to be specific about what you're doing, how you feel, whom you're with, etc.
List 3 things that are holding you back (bad habits, limiting beliefs, recurring challenges, etc.)
Who are the most important people in your life? Why? What do they do that makes them important to you? (Optional, but very helpful)
(Optional, but very helpful)
What are 3 behaviors/activities that you believe would be beneficial for you but have a hard time doing consistently/on a daily basis?
What has been your biggest success in life thus far? How did you achieve it? Who helped you? (Optional, but very helpful)
(Optional, but very helpful)
List 3-5 people you admire (living or deceased; personal or historical). What is it about them that you admire? What values do they embody? (Optional, but very helpful)
(Optional, but very helpful)
Describe your life the way you want it to be 5 years from now. Please write this in present tense (I Am...) and use only positive phrases (for example: "I’m in a loving relationship" vs "I’m not single"). Don’t hold back and be as specific as possible.
In 2 months from now, how will you know if your efforts/changes have been effective? How do you measure "success"? (Optional, but very helpful)
(Optional, but very helpful)
What kind of support would be most helpful for you over the coming weeks. What do you want from your CIT Clinics Wellness Team? Please be specific. (Optional, but very helpful)
(Optional, but very helpful)
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HEAL Questionnaire