To be completed before scheduling an Inward Bound Session:

Name:

Street Address 1:
Street Address 2:
City/State/Zip:
Country, if not US:

E-mail address:

Phone numbers:
Home:
Work:
Cellular:

Things in my life that I particularly like and are going well:

Things in my life that I particularly don’t like or that seem to be going badly:

Things that I find particularly confusing and wish could be clarified:

What I would particularly like to work on in one or more Inward Bound sessions:

Prior treatment from psychiatric, psychological or spiritual practitioners:

Current treatment from psychiatric, psychological or spiritual practitioners, including any tranquilizers or other psychoactive medications currently being taken:

By checking the box below, you agree to the following statement:

I understand that the visioning processes, coaching, etc. offered by Inward Bound are no substitute for medical or psychological treatment, that it is my responsibility to seek them should either be needed, and that I take full responsibility

for myself in this work.

Thank you! I look forward to speaking with you soon.