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Client Intake Form

All information shared is strictly confidential and used only to support your appointment.

I offer nervous system coregulation and relational reality sessions. This is not therapy, counseling, or medical care. I work with people to help them understand what their nervous system is communicating and build genuine safety over time.

My work is not a substitute for medical care, psychiatric treatment, or therapy. I do not diagnose, treat, or prescribe. If you are currently experiencing a mental health crisis please contact a qualified professional.

First name

Last name

Phone

Birthday

Year

Month

Day

How did you hear about me?*

PREVIOUS MODALITIES

Have you received any of the following? Please check all that apply.*

Reiki or Energy healing

Psychic readings

Mediumship

Hypnotherapy

Plant medicine or ceremonies

Breathwork

Therapy or counseling

Psychiatric care

Coaching

Other spiritual or holistic practices

If you checked any of the above please share briefly what your experience was like — positive, negative, or neutral

CURRENT SUPPORT

Are you currently working with a therapist, counselor, or psychiatrist?*

Yes

If yes, please describe briefly: Are you currently taking any medication relevant to your mental or emotional health?

Yes

GENERAL HEALTH

Are there any physical conditions I should be aware of before your session?

YOUR EXPERIENCE

Have you experienced any of the following? Check all that apply.

Relational trauma

Spiritual experiences that felt unsafe or destabilizing

Paranormal experiences

Feeling unsafe in a healing or therapeutic space

Feeling dismissed or misunderstood by a practitioner

Ongoing patterns in relationships that feel difficult to understand or change

COMING INTO THIS CONTAINER

What brings you here today?*

Is there anything currently feeling unsafe in your life or relationships?*

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

CONSENT

I understand the nature of this work and that it is not a substitute for medical or psychiatric care. I confirm that the information I have provided is accurate. I give permission for this information to be held privately and used solely to support my session.

Signature *

Date*

Year

Month

Day

Yes, subscribe me to your newsletter.

Miramichi, NB

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Nervous System & Relational Work
—Human and Otherwise

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