Welcome,

I’m so glad you are here!

The application should take about 10-20mins. Applications close when spots are full.

The requirements to participate are:

You have experienced abuse
Financial barriers impact your access to healing & support
You can come to Florence both for 6x1.5 in-person sessions between April 18-June 17th 2025
You speak english / greek / spanish

PERSONAL INFORMATION

First Name

Last Name

Pronoun

Age

Phone

(###)

###

####

Preferred communication method (check one)

Call

Text

Which of the following languages do you speak?

English

Spanish

Greek

Medical History. Does any of the following apply to you? If so, share any information it would be helpful for me to know.

Asthma, Cancer, Heart Condition, Diabetes, Hypertension, Psychiatric disorder, Epilepsy, TMJ, Substance use or abuse, Addiction, Anxiety, Depression, Allergies / Sensitivity, Sleep disorders, Grief or Heartbreak, Headaches, Contagious skin condition, Accidents or injury, High or low blood pressure, Circulatory disorder, Joint disorder /Rheumatoid arthritis / Osteoarthritis / Tendonitis, Decreased sensation, Back/neck problems, Emotional, physical or spiritual abuse, Extra-sensory perception or telepathic/kinetic abilities, Symptoms otherwise unexplained by the traditional medical model, Autoimmune disorders including HIV/AIDS, Fibromyalgia, Gastrointestinal / Digestion problems, Weight Gain / Loss, Pelvic floor / Genitourinary issues.

FAMILY INFORMATION. Do you have children? How many? Ages? Do they have any special needs?

FINANCIAL INFORMATION (Confidential) We strive to make this program accessible to those who face financial barriers to healing work. To help us understand your circumstances, please share what you feel comfortable about your financial situation.

This might include: Current employment or income challenges Experiences with systemic barriers or discrimination Lack of access to intergenerational wealth or financial safety nets Recent life changes affecting your financial stability Other factors that impact your access to healing resources Please share what you feel is relevant (no specific documentation required):

Financial Contribution

The total cost of participation in this program is $1,050, which includes 6 x 1.5 individual sessions with each participant & 3 x Contakids group workshops You can participate at no cost, or contribute whatever amount you feel able to afford. Any contributions from participants will help us expand the program and open more spots to more participants. Based on your current situation, what contribution (if any) would be manageable for you for the entire program?

PROGRAM INTEREST & NEEDS. Have you ever received bodywork, somatic therapy, or similar healing work before?

Share anything you'd like about it

What are you hoping to gain from participating in this program?

Scheduling. Sessions will be scheduled Monday through Thursday. Are you able to commit to attending regular sessions on these days? Do you have specific times during those weekdays that could work for 1-1 sessions and others for group sessions? If so, please share:

How did you hear about this program?

Documentation

We may record portions of the program (particularly group sessions) for documentation purposes. These recordings would only be used when seeking future funding to continue or expand this program. Would you be comfortable being recorded?

Is there anything else you'd like me to know?