Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Phone
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Country
(###)
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Email
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Emergency Contact
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First Name
Last Name
Emergency Contact Phone
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Country
(###)
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Are you currently taking any medications? If so, please list them.
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Have you ever participated in therapy before? If so, please briefly describe your experience.
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Have you previously participated in any form of surf therapy or outdoor therapy? If so, please briefly describe your experience.
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What services are you interested in?
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Counselling & Psychotherapy
Surf Therapy Programs
Surf 'n' Soul Sessions
More than one or all of them
What are your primary goals for participating in our programs?
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Do you have any past trauma, or are you currently dealing with any stress, anxiety, depression, or other emotional challenges?
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How do you usually cope with stress or difficult emotions?
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Do you have any physical limitations, injuries, or conditions that may affect your ability to participate in surf therapy or physical activities?
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Including surfing, yoga, any movement exercises etc.
How would you rate your current physical fitness level?
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(e.g., sedentary, active, athletic)
What is your current swimming ability?
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Non-Swimmer
Beginner
Intermediate
Advanced
Competent/Expert
Lifesaving/Professional
What is your current surfing level?
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Level 1.1: you are a total beginner
Level 1.2: beginner with limited experience
Level 1.3: beginner with experience
Level 2.1: intermediate surfer
Level 2.2: intermediate transitioning into an advanced surfer
Level 3.1: Advanced surfer
Level 3.2 Expert surfer
Are you comfortable in the water? If not, describe what your fears are.
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What are your expectations for your therapy experience?
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Is there anything specific you would like to focus on in your sessions?
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(e.g., stress relief, confidence, emotional healing)
Do you have any preferences or concerns about the type of therapy
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Individual vs. group, in-person vs. virtual, specific framework or technique, etc.)
What is your preferred contact method?
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Please provide your most direct method for communicating appointment information.
What days and times work best for you for sessions or program participation?
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I have read and agree to Mindswell Surf Therapy's Terms and Conditions.
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Yes
No
