Surrender Immersion

Name *

First Name

Last Name

Previous shadow work *

Have you done any previous shadow work inner deep inner work before?

No

Yes by myslef

Yes with a therapist or practitioner

Emotions *

Which emotions do you feel overwhelmed by

Saddness

Anger

Rage

Jelousey

Grief

Recentment

Limiting beliefs *

Which repeating thoughts do you have

I am all alone

I am un heard

I am un worthy

I am un loveable

I am not good enough

I dont deserve to be happy

I dont trust myself

I dont trust anyone

Patterns *

Do you suffer from

Anxiety

Intense emotions

Fear

Low self worth

Low self esteem

Low confidence

Ababdonment

Toxic relationships

People pleasing

Shame

Guilt

Frustration

Taking things personally

Procrastination

Panic attacks

Avoidance

Triggers *

I get easily triggered by others and situations

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Responsability *

I believe that it is my full responsibility for my healing.

Yes its my full responsibility

No its the person I am working with responsibility

Emotional maturity *

I am ready to sit with un comfortable and intense emotions, I understand deep inner work is not always going to feel good. I am ready to do the work.

Yes I understand and I am ready

No I am not ready

Habitual patterns *

I am willing and ready to look at my habitual patterns even if they are un comfortable to look at. I understand they are not my fault but they are my responsibility.

Yes I understand and I am ready

No I am not ready

Beliefs *

I am willing and ready to look at and question my limiting beliefs about my self, others and the world.

Yes I am willing and ready

No I am not willing or ready