Pre-Screen / Initial Inquiry Form

Thank you for your interest in Free Spirit Experience.
This short form helps us understand whether our program may be a good fit at this time.

*Completing this form does not guarantee acceptance and is the first step in the admissions process.

Estimated completion time: 10–12 minutes.

First name

Birthday

Last name

Primary Contact Name

Phone number

Is the paticipnt curretly receiving any form of thray or support?

Yes

Previously

If yes or previously, please describe briefly

Is the paticipnt curretly taking pescribed medicatin?

Yes

If yes or,please list the medication(s)

What brings you to explore Free Spirit Experience at this time?

What are you hoping the participant will gain from a program like ours?

Are there any significant medical, physical, or saftey conciderations we should be aware of at this stage?

If referred by a proffesional, please include their name

Is there anything else you feel is important for us to know at this stage?

Ooops, sorry about that, but something went wrong. Please check the answers and try again.

Thank you for submitting the form. We will contact you soon.