1:1 Sessions In-Take Form
Jaylyn Bernachi | Innerswim Institute | jaylyn@innerswim.com
Any information shared is confidential.
Full Name
*
First Name
Last Name
Age
*
Timezone/Location
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Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How do you prefer to be contacted?
By email
By phone
How did you hear about this offering?
Do you have any experience or history with Yoga, Yoga Nidra, Menstruality, Energy Medicine or Womb Yoga? If so, please briefly explain.
What draws you to a 1:1 session or program at this time?
*
How are you feeling in this current season of your life?
What tends to cause you stress or overwhelm right now? How do you usually ground or regulate yourself when things feel intense?
What does a typical day look like for you right now, from the time you wake up to when you wind down at night? Feel free to share your routines, habits, or anything that feels important about how your days usually flow.
Is there a specific theme, pattern, or challenge you’d like to work with?
What do you hope to gain from our time together?
*
Is there anything else you’d like me to know to help me support you best?
Consent and boundaries: I understand that these 1:1 sessions with Jaylyn are not a substitute for therapy or medical treatment. I agree to communicate openly and honestly during sessions. Check the box below to confirm your understanding.
Yes, I understand and agree.
Would you like to be added to my email list? I share news about upcoming events, special offers, and plenty of resources.
Sure
No thanks
Thank you! See you soon.
Love, Jaylyn
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