INTAKE FORM

For Use With One-On-One Coaching, Core Teams and Intensives
with Pablo Ceron and the WILDSONS / WildPath Teams

Please consider each question and share openly with us.
This is your opportunity for us to get to know you.

Your information is strictly confidential.
It will be used as we prayerfully prepare to walk with you on this journey.

NOTE:
We realize this is an extensive form. Since you cannot save your progress and come back to finish later, you may want to consider writing your answers on a Google Doc or other location where they can be saved, and then come back and paste each one on the corresponding field.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is your Date of Birth?

YYYY

What is your current marital status?

Please let us know if you're single, married, divorced, separated, widowed, etc. Feel free to provide any additional context that may be helpful (i.e. how long you've been married).

Do you have children?

If so, describe their gender, ages and your relationship with them.

Have you attended a WILDSONS Muster, Wild at Heart Basic, Becoming a King retreat or similar event?

Please list any events / programs that you have attended that may be relevant as we consider your application.

Historic Relationship with Family of Origin:

Briefly describe your relationship with your family of origin when you were growing up. (i.e. parents, step-parents, adoptive parents, siblings, etc.)

Current Relationship with Family of Origin:

How are your relationships with the members of your family of origin different today?

Other Significant Relationships:

Please list all other significant relationships or influential people from childhood to present. This includes grandparents and other relatives, really good friends, pets, and special support people who were there for you or who are there for you now and show they care. Please include any important affair relationships and what they meant.

Family Messages:

What were some of the messages, verbal and non-verbal, that you got from your family? Please include both negative and positive ones.

Losses in your life:

Please list all significant losses in your life including a death, divorce, friends, abortion, pets, betrayal, job or career, health loss, child’s impairment, etc.

Story of Physical and Sexual Harm:

Please list occurrences of physical or sexual abuse or unwanted sex. If you are not sure if something was abusive but feel it might have been then include it.

Other Key Life Events:

What other key life events have shaped you? Please describe all other significant events in your life story (positive and negative) that have shaped you into who you are today.

Physical Limitations:

Please describe any physical limitations such as chronic pain, recent surgeries, heart conditions, seizures, etc.

Addictions / Compulsive Behaviors:

Please describe any history (including present) of use of alcohol, chemicals, pornography, sexual compulsions or other behaviors that have had or are having negative consequences in your life. Are you involved in any recovery programs?

Relationship with God:

Please describe the history of your relationship with God (Father, Jesus, Holy Spirit), and how it is right now.

What's not working?

As you consider your life today—significant relationships, finances, health, work and calling, relationship with God, etc., what seems to be not working as you had hoped? Where are you striving? Where are you experiencing resignation?

What are you hoping the outcome / result of your work with us will be?

What are your heart's desires as you step into this journey?

Anything else to consider?

Please let us know if there is anything else you believe is important to know about you as we set off on this journey