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First name

Last name

Organization or School Name

Email

Phone

Which Rooted offering are you most interested in?

One-Day Immersive

8-Week Series

Extended Workshop (1.5–2 hrs)

Other

What inspired you to reach out about Rooted?

What are your goals for this experience?

What kind of space are you hoping to create for your students through Rooted?

What grade levels are you hoping to serve?

Middle School (6–8 grade)

High School (9–12 grade)

Mixed age group

Other

Estimated number of students participating

Fewer than 10

10-25

26-50

51 +

Are there any specific needs, challenges, or dynamics we should know about your student group?

Have your students had prior exposure to wellness or mindfulness practices?

Yes, regularly

Somewhat

No, this would be their first exposure

Not sure

Do you have a preferred time frame or specific date(s) in mind?

Is there anything else you’d like to share about your group or goals for this program?