Intake form

Please spend a few minutes reflecting upon the below questions before writing your answers. I want your answers to feel authentic to you so don’t hold back!

Personal details

Name: *

Address: *

Email: *

Phone Number: *

Age: *

Work

What is your profession? *

Do you enjoy your work? Why or Why not? *

Personal Growth/Health

What other modalities, practices or self-development work have you interacted with to help you reach your desires? *

*If you have undergone therapeutic treatment for any of the following: bi-polar/manic depression; post-traumatic stress; clinical depression; eating disorders; and/or suicide attempts, bring this up on our discovery call so we can determine together if coaching is a good fit for you at this time.

Coaching Questions

What are three things you most want from our time together? *

What are three things that you want to move through/ release/ transform in our time together? *

Please share your 3 biggest strengths: *

What are the biggest challenges in your life right now? *

Can you share a few paragraphs of your sexual history that feel relevant to our work together? *

Do you have an intimate relationship (husband, wife, life partner, boyfriend, girlfriend, etc.)? If so, what is the quality of that relationship? What is great about it? What needs work? *

What are you afraid of about working together? *

What can I do that will make you feel safe and supported in our work together? *

Is there anything else you would like me to know?

What are your preferred pronouns? *

At times we may discuss genitalia and areas such as the womb or womb space, cervix, etc. What terms do you prefer for these areas and/or what terms are triggering or offensive to you? *

Physical Health

In this work, clients may experience physical symptoms as part of releasing a long-held wounding pattern. Even if you believe that what the client is experiencing is related to your work together, it is always best to ask clients to check with their personal doctor. Are there any symptoms I should be aware of that could affect your experience? *

Consent for Practices

Some of the practices in mine and the VITA™ Methodology which I use are sexual in nature, and it is important that you can consent to do these practices before we begin. This is true of practices that use sensual touch, self-pleasure, massage, the jade egg, and even some breathwork. Any practices that involve the above will be done in the privacy of your own space and without me present and/or able to visibly see/hear you. If this is a concern for you, please list any concerns below and if there are any practices you do not consent to? *

We may do practices using breathwork which is not advisable if you have any of the following conditions: • asthma, • epilepsy, • strokes, • seizures, or • are pregnant. Are you affected by any of the above? *

Finance

Are you ready to invest in coaching? *

Yes

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