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Welcome

Thank you for your interest in having a session with me.


The following Client In-Take has eight sections and must be completed to book a session with me. This Client In-Take is expected to take around 7-10 minutes to fill out. 


If you book multiple sessions with me, you will only have to fill out this Client In-Take Form once. This Client In-Take will inform me of your important goals with our session. Your goals are subject to change throughout our coaching. The information you provide here will indicate a starting point.


Privacy: Information you share within this Client In-Take Form will never be shared.

Client Approval

  • I am currently only selecting a small number of people for session work.

  • I am only accepting individuals 18 or older at this time.

  • I currently can provide my services in English.


I am not currently taking clients currently undergoing extreme mental health symptoms; extreme disassociation, overly frequent nightmares, substance abuse, addiction, compulsion, hyper-fixation, excessive mood swings, excessive rumination, psychosis, or any symptom that impacts the nature of the mind.


My sessions are not a replacement for therapy or professional mental health services.

Client Health & Saftey Commitment

For safety reasons, this Client Intake will take information about your current mental and physical health that may impact the relationship to your nervous system regulation.


If at any point critical information about your mental or physical health changes that impact my ability to safely be a partner in your self-development process, a client is to report these changes to me before booking their next sessions.


I will update the information within your Intake accordingly to continue to best serve you or refer you to another practitioner that is better to serve your needs.

Session Topic Restrictions

The following topics and conditions can not be serviced or discussed within your session:


  1. Mental Health Diagnosis

  2. Information On Mental Health Symptoms

  3. Intrusive Thoughts

  4. Hyper-fixation

  5. Excessive Rumination

  6. Compulsion

  7. Excessive Disassociation

  8. Addition

  9. Depersonalization & Derealism

  10. Providing Therapeutic Services

  11. Behavioral Changes Due To Brain Damage

  12. Abusive Relationship Dynamics

I have read the information above. I agree to answer the following questions within this Client Intake honestly.

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