Client Intake Form hope

Client Information and Intake Form

Practitioner: Hope Devaney guidedwithhope@gmail.com - 0426715885

Name

First NameLast Name

Email

example@example.com

What is your primary concern that leads you to want to work with me

What kinds of things do you currently do for selfcare mindfulness exercise time in nature good nutrition connections with loved ones etc

Have you done or do you do any other modalities for your wellbeing such as spiritual practices meditation healing work etc

Are there any life experiences in your past that were very difficult for you and that still trouble you

With regards to your nervous system how often do you experience any of the following anxiousness stressed out frustrated fearful shut down disconnected or in a freeze mode

What do you do in your life currently or in the past that gave you the most fulfillment inner peace and sense of contribution and connection

Please add any additional information that you would like to share

Learn about the Embodied Process here

Hope is not a licensed doctor or therapist. She is trained and certified as an Embodied Processing practitioner, and specializes in nervous system education and skill building. She offers coaching for nervous system regulation and emotional processing, self-awareness and general spiritual wellbeing. She does not diagnose, treat or prescribe for any physical or mental health illnesses. If you have a health concern please see your doctor or other qualified healthcare practitioner. Hopes offerings can be a wonderful addition to and enhance other modalities. Everything you share with Hope is completely confidential.

After reading all the above please sign indicating that you have read and agree with all the above*

Date

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