Ceremony Questionnaire

Interested in going deeper on your own healing quest in a safe and supportive community? Become a member of Colibri Heal In.

Fill out the membership application with honest offering. This membership is about commitment to yourself and others. Membership includes access and discounts to events, merchandise, and programming at our retreat center in McDonough, GA as well as internationally.

Membership Application

So grateful that you’re taking this step towards enhancing your life.

Being that you even made it to this point of the website means that you are ready to take the next step in actualization. Please take care in filling out the application below. Once submitted, allow 1-2 weeks to receive notification from a member of the Colibri Heal In staff.

First Name

Last Name

Preferred / Spiritual Name

Gender

Male Female

Date of Birth

Time of Birth

Location of Birth

Relationship Status

Phone Number

Permanent Address

Address Line 1

Address Line 2

City

State / Province

Zip / Postal Code

Country

Emergency Contact

Relation to Emergency Contact

Emergency Contact Phone Number

What is Your Intention for Becoming a Member?

General & Mental Health Information

Have you ever gone to the hospital for mental health reasons?

Yes No

Have you ever gone to the hospital for substance abuse reasons

Yes No

If so, please list approximate dates

Current Medications

Past Medications

How would you best describe your current physical health?

How would you describe your current sleeping habits?

How would you describe your appetite

Exercise

Chronic Pain

Current Medical Updates

Family & Mental Health History

If you or any of your family has a history of any of the following, please indicate and briefly describe.

Health Problems

Mental Health Problems

Substance use/abuse/dependence problems

History of abuse or domestic violence

Legal Problems

Economic Problems

Occupational Problems

Housing Problems

Trauma History

How often have you experienced each of the following in the last two months? (0 = Never, 3 = Often)

Headache

0 1 2 3

Insomnia

0 1 2 3

Weight Loss (without dieting)

0 1 2 3

Stomach Problems

0 1 2 3

Sexual Problems

0 1 2 3

Feeling isolate from others

0 1 2 3

Flashbacks (sudden, vivid, distracting memories)

0 1 2 3

Nightmares

0 1 2 3

Spacing Out (going away in your mind)

0 1 2 3

Sadness

0 1 2 3

Dizziness

0 1 2 3

Not feeling satisfied with your sex life

0 1 2 3

Trouble controlling your temper

0 1 2 3

Waking up early in the morning and can't get back to sleep

0 1 2 3

Uncontrollable crying

0 1 2 3

Fear of men

0 1 2 3

Not feeling rested in the morning

0 1 2 3

Trouble getting along with others

0 1 2 3

Memory problems

0 1 2 3

Desire to physically hurt yourself

0 1 2 3

Fear of women

0 1 2 3

Passing out/fainting spell

0 1 2 3

Feeling that things are "unreal"

0 1 2 3

Unnecessary or over-frequent washing

0 1 2 3

Feelings of inferiority

0 1 2 3

Feeling tense on a regular basis

0 1 2 3

Being confused about your sexual feelings

0 1 2 3

Desire to physically hurt others

0 1 2 3

Feelings of guilt

0 1 2 3

Feeling that you are not always in your body

0 1 2 3

Having trouble breathing

0 1 2 3

Sexual feelings when you shouldn't have them

0 1 2 3

Strengths & Areas of Growth

What areas in your life could you improve in?

What are your strengths?

Where do you go for strength when your resources are exhausted?

Treatment Healing History

What type of healing services have you utilized prior to this?

How have they helped you? How were they not helpful?

What would you like to contribute to the world?

What do you expect from this process?

Why Us? Why Now?

What brings you to Colibri-Healin at this particular time in your life?

How have you evolved as a person over the last year?

What currently gives you a sense of purpose and meaning in your life?

What role does spirituality play in your life?

What is going on in your life right now? What challenges are you facing?

Where are you in balance in your life right now? Where are you out of balance?

Do you have any repeating patterns and habits you would like to change?

What's the biggest change you want to make in your life in the next 3 months? 6 months? 9 months? 1 year?

What are the biggest changes you want to make over the next 3 years?

What is currently keeping you from making these changes?

What are your 3 greatest accomplishments to date?

What is your relationship like with your family?

What role do you play in your family? How does your family contribute to your wellbeing? In what ways do they contribute to your stress?

What is the hardest thing in your life that you've had to overcome? How did you do it?

Who are/have been your major role models? Why?

Finances | What is your relationship to money? How does money impact your wellbeing

Physical Environment | How organized are your "spaces?" How does your environment impact your wellbeing?

Career | What personal strengths do you use in your career? What challenges are you currently having? How does your career impact your wellbeing?

Leisure/Hobbies | What do you spend most of your leisure time doing?

I agree to the Waiver.

I have read and understood this waiver, have had time to reflect upon it, and sign this waiver voluntarily. (Please sign by typing your full name below. This will act as your official signature.)