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The Enrollment Worksheet form must be completed prior to attending a Heart of Asheville workshop. The form is 5 pages long and asks a series of questions to help us better understand you and your situation. For security purposes you will not have  the ability  to save the form at any time. If you have any issues or questions, please feel free to contact us. Relax and enjoy your journey! 

Note: All information is CONFIDENTIAL and will be read only by the instructors and your assistants.

  1. Heart of Asheville LogoHEART of Asheville Enrollment Worksheet

    Note: All information is CONFIDENTIAL and will be read only by the instructors and your assistants.

  2. Full Name(*)
    Please type your full name.
  3. Name on Name Tag(*)
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  4. Street Address(*)
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  5. City(*)
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  6. State(*)
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  7. Zipcode(*)
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  8. Daytime Phone(*)
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  9. Evening Phone(*)
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  10. Cell Phone(*)
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  11. Fax
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  12. E-mail(*)
    Invalid email address.
  13. Birthdate(*)
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  14. Occupation(*)
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  15. T Shirt Size(*)
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  16. For meals do you prefer vegetarian(*)
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  17. Referred By
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  1. Are you(*)
  2. Describe Your Relationship(*)
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  3. If you have children describe your relationship with them
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  4. Describe your relationship with your parents
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  5. Have you ever completed any other personal growth course(*)
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  6. If YES what and when
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  7. Are you currently in counseling(*)
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  8. What were the results
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  9. Any major physical illnesses or injuries(*)
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  10. If YES please describe
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  11. Please list all medications you are currently taking
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  12. Have you ever served in the armed forces(*)
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  13. If YES please describe when and where
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  14. Employed by
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  15. Describe your job responsibilities
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  16. Are you a student(*)
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  17. If YES area of studies
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  1. Please tell us a little about your family.
  2. Your Mother
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          Please answer the following questions:
          First Name
          Age
          Occupation
          Most dominant personality trait
          If deceased, when?

  3. Your Father
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          Please answer the following questions:
          First Name
          Age
          Occupation
          Most dominant personality trait
          If deceased, when?

  4. Your Sisters
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          Please answer the following questions:
          First Name
          Age
          Occupation
          Most dominant personality trait
          If deceased, when?

  5. Your Brothers
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          Please answer the following questions:
          First Name
          Age
          Occupation
          Most dominant personality trait
          If deceased, when?

  6. Your Significant Other
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          Please answer the following questions:
          First Name
          Age
          Occupation
          Most dominant personality trait
          If deceased, when?

  7. Your Daughters
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          Please answer the following questions:
          First Name
          Age
          Occupation
          Most dominant personality trait
          If deceased, when?

  8. Your Sons
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          Please answer the following questions:
          First Name
          Age
          Occupation
          Most dominant personality trait
          If deceased, when?

  1. Early recollections illustrate how we dealt with events or incidents in our early childhood and how we felt at that time.  Below please describe at least two (2) early childhood recollections. An early recollection is the memory of a specific event or incident that occurred to you in childhood. Be sure to include how this event made you feel.

    An example would be:

    Age 4-5 --- One day riding my tricycle the neighbor’s dog started barking and running toward me. The dog was on a leash, but I fell off my tricycle and ran home crying. My brother laughed at me and my mother sent me to my room until I calmed down. I felt scared, embarrassed, small, misunderstood, and unlovable.

  2. Early Recollection 1
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  3. Early Recollection 2
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  4. Please list THREE goals you would like to work toward.
    One for you personally.
    One for your career.
    One for your relationships.
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  5. Additional information you wish to share
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  1. Are you currently under the care of a therapist psychologist or psychiatrist(*)
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  2. If YES will you give us permission to call them
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  3. Doctors Full Name
    Please type your full name.
  4. Doctors Daytime Phone
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  5. Have you ever been hospitalized in a psychiatric facility(*)
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  6. Do you have any physical disability or medical condition that may impede your ability to participate in physical or experiential aspects of this workshop(*)
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  7. If so please describe
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  8. By signing this Enrollment Agreement Form, I agree to ALL of the following terms and conditions:

    • I agree to attend, in entirety, all sessions of the workshop:
    • I agree to be on time for each session;
    • I agree to return the completed Workshop Information Sheet (WIS) at least 10 working days prior to the course;
    • I agree to not take any non-prescription drugs or drink alcohol within 24-hours of ANY session.
    • I have read and understand the Informed Consent Terms.
    • I have read and understand the Cancellation/Refund Policy.

    As a participant in the Heart of Asheville Course, I agree to respect the confidentiality of all participants.  This does not preclude me from sharing my experience of the course.

     

  9. I agree(*)
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    Your completed form and selecting YES I agree is your consent in lieu of your signature.
  10. Security
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