New Client Intake Form

This application is designed to help me understand where you are, what you’ve been navigating, and whether this mentorship is the right container for your healing journey.

You are welcome to share only what feels appropriate. You do not need to tell your entire story here, and you do not need to have perfect words or complete memories.

First & Last Name

Phone Number

Age

Location/Timezone

What is bringing you to seek support at this point in your life?

What feels most important for us to understand about what you are currently experiencing?

If this mentorship created meaningful change for you, what would be different in your life 3–6 months from now?

What are you longing to return to, reclaim, or create?

How would you describe your current relationship with yourself?

Where do you feel most disconnected from yourself?

How do you notice stress showing up in your body?

What are your earliest signs that you are becoming overwhelmed?

When you feel unsafe, threatened, or emotionally activated, what tends to happen?

What helps you return to yourself?

What healing, therapy, coaching, or personal growth work have you done previously?

How would you describe your experience in close relationships?

When someone you love feels distant, unavailable, or upset, what happens inside you?

What relationship patterns do you notice yourself repeating?

What would a healthy, connected relationship feel like to you?

What experiences have significantly shaped you?

Were there experiences where you learned you had to disconnect from parts of yourself in order to cope?

If you know, what was your early environment like?

What did you learn you needed to do to receive love, approval, or acceptance?

Are there physical experiences that feel relevant to your healing journey?

How would you describe your relationship with your body?

Is spirituality, intuition, or connection to something greater part of your life?

Have you worked with Somatic Experiencing, Parts Work, Inner Child work, or similar approaches before?

What draws you specifically to this mentorship?

How ready do you feel to actively participate in your healing process?

What support would help you feel successful in this container?

Which 1:1 container are you applying for? Required

Single Sessions

3 Months: Every Other Week

3 Months VIP: Weekly Sessions

Are you currently able to commit the time, energy, and financial investment required for this work?

Is there anything else you would like me to know before we connect?

New Client Intake Form

Contact