Innerawesome Six-Week Program Intake Form

Contact Information






Medical History
This section is used to help us understand you better. All fields are considered sensitive and follow strict data standards. This data is confidential, secure, and will never be shared.








What are you looking to get out of this program?

Please consider the following:

Although the program is based in creating safety there might still be some risks Associated with mindful interventions and deep inquiry, please read below to make sure you understand the risks associated with this work:

The movement practices are very gentle and they main focus is on stretching and awareness of the breath during movement.  You are also not obligated at any time to engage in any practice you feel may be uncomfortable or unsafe.

As your awareness grows and you are beginning to sense more deeply, and understand more clearly, you might start to notice that you have been disconnected from your body and your emotions, this could feel as something new  or even uncomfortable to be with but keep in mind that it is just the awareness of what was already happening that might make it seem as a new experience.

In our experience there are a few circumstances that may require additional support to manage this experience.  In some situations the emotional load an individual is carrying can take on a particularly painful and challenging character and in those cases we often strongly encourage that person to have an additional safe place, usually a therapist or counselor, where they can talk, process, and heal the difficulties that are being unearthed and illuminated by the light of mindfulness practice in innerawesome.

For example, if a person is carrying severe trauma and suffering from PTSD the flashbacks may become more intense, at least at first, and the need to process the experience in therapy of some kind may arise.  If a person struggles with anger issues, with growing mindfulness they may feel the intensity of their anger or the harshness of their angry thoughts more deeply.  In such instances the very intensity of the pain–made clear by mindful awareness–can be the doorway to healing if the person chooses to work skillfully with an anger management specialist or a skilled trauma therapist, and can use the authentic self-awareness developed by their mindfulness practice to inform their treatment.

Please be assured many, many, participants carrying one or more of these challenges have successfully completed the program finding that learning to live with intention helps them discover a new way of life.  

The program is designed to benefit people at all levels of personal development!  With good advance awareness and utilization of proper support remarkable healing is possible for anyone.

Informed Consent Agreement
I understand the risks, benefits and possible side effects of a mindfulness-based Program as explained to me above. It's my responsibility to clarify or ask questions if I am unclear about the program or the exercises involved. 

The program includes skill training in mindfulness and meditation as well as deep guided inquiry and in-class body awareness interventions. 

I understand that if for any reason I am unable to, or think it unwise to engage in these techniques and exercises either during the weekly sessions or at home on my own, I am under no obligation to engage in these techniques nor will I hold the above named facilities nor the facilitator (Alex Maizussliable for any injury incurred from these practices.

Furthermore I understand that I am expected to attend each of the six (6) classes, including for a duration of 1.5 hours and to practice the home assignments for at least about 30 minutes per day during the duration of the training program.

CANCELLATION & REFUND POLICY 
Please note the following terms regarding cancellations and refunds:

  • After the first session: No refunds will be issued. However, a 50% credit toward a future program will be honored if cancellation occurs before the second session.
  • After the second week: No refunds or credits will be provided beyond this point.
  Thank you for your understanding and commitment to the process.

RECORDING
Portions of the lessons might be recorded for training purposes but will not be distributed to class attendees.

EMAIL CONTACT
I agree that during the class the instructors can reach and communicate with me via
the email address I’ve provided.

EMERGENCY CONTACT

I grant permission for the instructors to contact my emergency contact in case of emergency.

ZOOM
I acknowledge that sessions are held on Zoom and even though it is secured and encrypted site it is still similar to using cell phones, email, and social media, privacy may be compromised which can lead to breaches of confidentiality.