Intake Assessment

Journey Intake Assessment

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Name *

First

Last

Email *

Thinking about yourself now vs. post Journey, please describe the outcome you most desire. *

Tell me about your life.

What three words would you use to describe your life right now? *

What are some things in your life right now that bring you joy? *

Tell me a little bit about the people you share time with. *

What are your greatest achievements / the things you are most proud of? *

Tell me about yourself.

Thinking of yourself as a whole, what three to five words would you use to describe yourself? *

What do you love most about yourself? *

What are some patterns of thoughts or behaviors you currently have that you would like to see change? *

What do you think may be the cause of these patterns? Are you able to reflect on this to pin-point a feeling (in your emotions or in your body) that arises when you are playing out these patterns? *

Tell me about your health and healing.

In the past five years, what other healing and wellness programs have you done? What help have you received? You could list doctors, programs or even self-help books here. *

Do you have a psychological diagnosis? *

Are you currently taking prescribed or over-the-counter pharmaceuticals? *

Are you currently regularly taking herbal medication? *

I invite you to share some extra information with me.

Birth Date, Time and Location *

If you have experienced a notable (strange) dream recently, I invite you to share it with me. *

What is your earliest childhood memory? *

Ecosophy Pledge

The Ecosophy pledge is founded in the Toltec wisdom of the five agreements.

I, Danae Jensen, pledge to be impeccable with my word. I will speak with integrity throughout my Journey. I will remember that nothing anyone else does is about me and that others are living and reacting from their own place of reality. I will not make assumptions but rather, I will ask questions with an open and curious mind. I will listen to others with the intention of understanding, knowing their truth may not be the same as my truth. This pledge is made with the grace of my humanity, imperfectly, but I will do my best.

I invite you to take the Ecosophy Pledge as well. *

I pledge

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​Journey Intake Assessment

Ecosophy Pledge

Journey Intake Assessment