Name *

First Name

Last Name

Phone

(###)

###

####

Section 1: AWARENESS: Which of these emotions or patterns are you struggling to move through right now? *

(You are choose more than 1)

Anxiety

Sadness or grief

Frustration or anger

Overwhelm or overthinking

Numbness or low energy

Lack of clarity/direction

Loneliness or disconnection

Self-doubt or insecurity

Other

Which of these statements do you most relate to? *

Select as many as you need

I feel calm and connected with others.

I often feel numb or disconnected forom myself, others and the world.

I often feel anxious or on edge.

I find it easy to relax, switch off and be present.

I often find it difficult to 'take a deep breath'.

I often feel overwhelmed and withdrawn.

I feel safe expressing myself.

I feel restless or impatient.

I have trouble motivating myself (distracting or procrastinating)

Section 2: RESOLVE: What qualities or emotions best describe what you would like to embody or move towards? *

(You are choose more than 1)

Confidence

Clarity

Forgiveness

Peace

Empowerment

Joy

Trust

Letting go

Compassion & Connection (self/others)

Other

Section 3: CO-CREATION: Is there anything that you do NOT want to include in your sessions together? *

The journey may include these elements features. If you are happy with everything then please select the final option.

Yin yoga / restorative movement

Gentle flow or dynamic practice

Breathwork/ Pranayama

Energy healing (Reiki)

E-motion healing/ visualisation

Accupressure

I am happy with everything

How much support feels right for you right now? *

(Your choice can be adjusted month-to-month based on your needs and budget.)

1 session per week (4 sessions/month) – steady support and space to integrate

2 sessions per week (8 sessions/month) – deeper support and faster momentum

Consent and Confidentiality *

I understand that this intake form is part of a holistic healing process using Five Element Theory, Vedic Wisdom, and Polyvagal Principles. The information I provide is confidential and will be used solely to tailor my healing journey. I acknowledge that this service is complementary and not a substitute for medical or psychological treatment. I consent to engage in this healing work with full awareness.

I agree and consent to the terms above.