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Enter Contact Information

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Date of Registration

First Name

Last Name

Married Name

Preferred Name

Date of Birth

Place of Birth

Time of Birth

Telephone/WhatsApp Number

Current Country of Residence

Work Experience

Current Occupation / Service

How did you discover EARTHWALK Shool of Evolution?

Mother’s Name

Mother's Date of Birth

Ethnicity of Ancestry inherited from Mother

Any significant illness or trauma? (Mother)

Father’s Name

Father's Date of Birth

Ethnicity of Ancestry inherited from Father

Any significant illness or trauma? (Father)

History in chronological order of any trauma, conflict or illness … Age & Details (please)

Describe your relationship with your Biological Mother.

Describe your relationship with your Biological Father

Describe the relationship between your Biological Mother & Father.

Describe your relationship with any Step-Mother(s).

Describe your relationship with any Step-Father(s)

Describe your relationship between your Biological Mother & Father & your Step Mother & Father.

Significant Relationships with any Extended Family Members?

Personal Intimate Relationships and Sexual History. Please include any; abuse, pregnancy, miscarriage, or abortion.

Do you have a Current Intimate Relationship?

If ‘Yes’ please provide details for each child; otherwise, enter N/A.

Child's Full Name

Child's Date of Birth

Child's Age

Child's Full Name

Child's Date of Birth

Child's Age

Child's Full Name

Child's Date of Birth

Child's Age

Briefly describe your relationship with each child.

Brief description of Personal Development Path to date.

Have you experienced working with any form of psychedelics? If ‘yes’ please provide details…

Do you have an established morning practice? If so, what does this include?

Do you have any addictions/distractions? If ‘yes’ please provide details …

Have you ever been diagnosed with any Mental Illness, ADHD, or similar? If ‘yes’ please provide details …

Are you taking any Prescription Medication or Self Prescribed Plant Medicines? If ‘yes’ please provide details …

Do you have any fears? If ‘yes’ please provide details …

What do you consider are your gifts?

What do you consider are your strengths?

What do you consider are your weaknesses?

Where would you like to imagine yourself in 3 years from now?

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