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First & Last Name
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Birthday
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Year
Month
Day
Email
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Phone
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Address
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What life-altering illness do you live with?
*
HIV
Hepatitis C
Cancer
MS
ALS
Other
Thinking of your personal wellness aspirations, what is your motivation(s) for being a member at VFFLS?
To be a part of a community
To gain a sense of belonging
To develop & maintain coping strategies for my health
To access services offered
Pain relief
Stress relief
To achieve better health in body & mind
To talk without judgement
Other
What are your wellness aspirations?
To be able to proactively / better manage my health & wellness
To improve / maintain my mental well being
To improve / maintain my emotional well being
To improve / maintain my spiritual well being
To reduce pain levels / ensure pain is not exacerbated
Other
What type of wellness practises most interests you?
Accupuncture
Lunches
Counselling
Massage Therapy
Educational Seminars or Workshops
Naturopathic Medicine
Reflexology
Yoga
Art Therapy
Reiki
Creative Expression Workshops
Other
Would you be willing to volunteer / share your skills with VFFLS?
*
Personal Health Number
How did you hear about The Vancouver Friends For Life Society?
I agree to the terms & conditions
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