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Client Intake

Welcome,

Thank you for taking this brave and exciting step towards building a more wholesome, integrated, and harmonious relationship with yourself. You are entering a new era of your sexual awakening and empowerment. I am honored to be taking this journey alongside you and to be holding space for you to come into a greater state of healing, expansion, and freedom.

As this is intimate and powerful work, it’s important for me to gather some information before the actual sessions. This gives me an idea of where you are at, it establishes a clear foundation of communication between us, and will assist me to get a feel for whether we would be a good fit to take this deep dive journey together.

Please fill out the intake form as honestly and completely as possible. This will give you an opportunity to connect with your goals, and intentions, and allow me to support you in getting the most out of your experience.

*ALL INFORMATION PROVIDED IS STRICTLY CONFIDENTIAL AND WILL NEVER BE SHARED WITH ANY THIRD PARTY AT ANY TIME.

Let's go.

Start

Let's first dive a bit into your PERSONAL background

No judgement, just answer all questions as honest as possible.

Question 2 of 21

Why are you feeling called to receive coaching/mentorship?

Question 3 of 21

What is your current biggest challenge related to intimacy & sexuality?

Question 4 of 21

What does your current embodiment/spiritual/meditative practice look like?

Question 5 of 21

Please describe any specific intention's you have for our time together:

Question 6 of 21

Have you ever received coaching/therapy similar to this before?

If so, how was you're experience?

Now we move onto the MIND/BODY HEALTH ASSESSMENT

*This assessment is for my own understanding of working with potential past trauma so that I can take this into our sessions.

Question 8 of 21

Do you have any history with psychological or physical health issues?

If so please share what they were and what therapy/guidance you sought. Are they active or resolved?

Question 9 of 21

List any medications or drugs, legal or illegal you take on a regular basis (include birth control, alcohol, marijuana, tobacco, caffeine, sleep aids, anti-depressants, etc.)

If you use medications, please share what they were for as well as the period of time you're taking them.

Question 10 of 21

Have you experienced any sexual trauma or abuse at some point in your life, including verbal:

Question 11 of 21

Do you have a history of chronic illness/fatigue/fibromyalgia or chronic/complex trauma (PTSD)?

If yes, are you under someones care?

Please list their name + name of their practice below

Question 12 of 21

Emergency contact and information (and their relationship to you)?

Finally, some agreements

Please read them carefully

Question 14 of 21

I agree that this is a transformational experience & that feeling resistance and tension is a normal experience. I agree to not run, but to lean into this experience. I acknowledge that this is where I will experience my deepest growth. 

A

I agree

B

I do not agree

Question 15 of 21

I acknowledge that these processes may bring up deep emotional release, physical tensions and traumas. I acknowledge that I am consenting to this process and knowing this, am responsible for my choice to enter this training experience. 

A

I agree

B

I do not agree

Question 16 of 21

I understand that this training/journey is powerful and I acknowledge the importance to clear my schedule of busyness so that there is space for healing & integration to take place.

A

I agree

B

I do not agree

Question 17 of 21

I agree to create a private and sacred space for the zoom sessions, without others in the room (if online).

A

I agree

B

I do not agree

Question 18 of 21

I know that payment is final and an energetic investment in my path.

 

I trust my intuition and choices to make this decision to choose Amanda as my mentor and I trust choose to trust the path that follows. 

A

I agree

B

I do not agree

Question 19 of 21

I commit to keeping a 'energetically clear space' meaning... 

 

I agree to name/bring in if there are any, tensions, challenges or contractions arising within me during our journey together 

A

I agree

B

I do not agree

C

I need more clarification on what this means

Question 20 of 21

I commit to giving myself fully to this journey, in surrender to that which is greater than myself. 

A

Yes! Let's dive in

B

I need more support in understanding this.

Thank you for filling in these questions!

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