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General Info

Your Name

Age

Date of Birth (International students, please be sure to put the month first)

Current Address

Street/Box

City/Town

State/Province

Zip/Postal Code

Country

Health

Are you currently on any type of medication?

YesNo

If yes, what is the medication? What do you take it for?

Will you be on this medication during the 18 Inch Journey?

YesNo

Do you currently have any physical limitations? (ex. chronic pain, obesity,
persistent injury, recent surgery, etc.)

YesNo

If yes, please explain:

Do you currently, or have you ever had, any diagnosed mental disorders? (ex. bi-polar disorder, OCD, Autism Spectrum Disorder, Compulsive Lying, ect.)

YesNo

If yes, please explain:

Eighteen Inch Journey - Applicant Intake Form

Daily Life

1. How are you feeling about living in community?

2. Are you currently working? If so, what has work looked like?

Family & Relationships

1. We realize that everyone typically experiences beautiful and difficult things within family. Please briefly describe the family you grew up in. What are some things you would like us to know about your family of origin?

2. What is something about your family upbringing that you feel grateful for?

3. What is something that's been challenging about your family upbringing?

4. What is your ethnic background?

5. Have you considered how race and ethnicity are a part of your wholeness journey? Please reflect.

6. Are you currently in a relationship?

YesNo

As you know, we care deeply about relationships. Please share a little bit about your relationship, including how long you’ve been together and the name of your dating partner:

Communication & Learning

1. Would you consider yourself more of an internal processor or external? Please elaborate, and feel free to discuss both if they overlap for you.

2. In your application, you let us know if you have experienced or currently experience any struggles that can affect how you learn. Is there anything you would like to add or elaborate on about how you learn?

3. What do you view to be your greatest strength?

4. What do you view to be your greatest weakness?

Leadership

1. Do you currently have leadership, mentorship or coaching in your life? If so, what does that look like?

2. We realize inviting leadership into your life can be a vulnerable thing.
Is there anything in your story you'd like to share with us that might impact the way you relate to leadership?

Eighteen Inch Journey - Applicant Intake Form

Personal History

We recognize that each of you have already answered these questions in detail. We are asking you to submit your responses to these questions again, as things may have changed since the time of your application. Please remember: our desire is to know where you are at, so that we are able to lead you well. Please answer with honesty and vulnerability.

In this section, please describe your history and current status with the following. If you do not have any personal history in the following areas, you may communicate that in your answers. If we are the first person you are sharing this information with, please include that in your answer.

1. Alcohol:

2. Tobacco:

3. Illegal drugs (including marijuana):

4. Eating Disorder (i.e. anorexia, binge eating, etc.)

5. Pornography. If you have experience with this, please include the most recent time you engaged pornography, your typical frequency, and when this pattern started:

6. Masturbation. If you have experience with this, please include the most recent time you engaged masturbation, your typical frequency, and when this pattern started:

7. Sexual Activity (i.e. foreplay, oral sex, sexting, intercourse). If you have experience with these, please include the most recent time you engaged sexual activity:

8. Same Sex Attraction (We define same sex attraction as experiencing a sexual propensity toward one's own gender).

9. Homosexual Behavior (We define homosexual behavior as engaging in sexual activity or a romantic relationship with a member of one's own gender).

10. Anxiety. If you have a history with this, please share what your experience was or is like when you feel anxious, and whether you have experienced panic attacks:

11. Depression.

12. Counseling. (if you have experience with this, please include what for and the time period)

13. Have you ever experienced physical trauma or illness? (i.e. chronic pain, cancer, major car wreck, surgery, etc.)

YesNo

If yes, please explain

14. Have you ever exhibited self-destructive behavior (i.e. cutting, compulsive lying, suicidal tendencies, etc.)

YesNo

If yes, please explain

Eighteen Inch Journey - Applicant Intake Form

15. What are 2-3 events in your life that have shaped the way you see yourself or the world?

16. Is there anything about your life or current situation that may affect your process during the 18 inch Journey that would be helpful for our team to know?

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Assignment

Eighteen Inch Journey - Applicant Intake Form

Eighteen Inch Journey - Applicant Intake Form

Eighteen Inch Journey - Applicant Intake Form