Sovereign Women - The Journey into Self Liberation Intake Form

1
Welcome!

There has never been a more important time to anchor in Self Trust and I am so glad you are here!

My intention with this container of Sovereign Woman – The Journey into Self Liberation is to re-awaken your awareness of your own capacity for trusting your self, your body and your intuition so that you can move through the threshold of your current expansion gap for true freedom.

My agreement to you is that I will show up fully for you and every part of you will be met with acceptance and love.

Over the 10 weeks of this group container together, we will move through an intentional process which is designed to guide you deeper into connection with your own inner wisdom.

While this container can be deeply supportive, it may not be the most aligned starting point for everyone at this moment and that’s okay, because my intention is always to ensure that you are entering a space that feels supportive, safe and truly resourced for where you are right now.

Your responses help me understand whether the group container is the most supportive option for you, or whether 1:1 sessions may better serve you at this stage of your journey.

There is no “right” or “wrong” outcome here only what best supports your nervous system, integration and capacity to receive.

Love Sian
2
Name
First Name
Last Name
3
Phone Number
4
Email
example@example.com
5
Date of Birth
Date
Month
Day
Year
6
Current Location
7
What’s calling you towards this container at this point in your journey?
8
What are you hoping to receive, experience, or reconnect with through this container?
9
Have you participated in group containers, circles, or programs before? If so, what supported you and what didn’t?
10
How would you describe your current capacity to be in a group container?(e.g. grounded and resourced / curious but tender / feeling quite raw or overwhelmed)
11
When strong emotions arise, what support tends to help you most?(e.g. group presence, 1:1 support, solo integration, not sure yet)
12
What is your experience with embodiment, breathwork, nervous system, or spiritual practices (if any)?
13
What, if anything, are you currently seeking support or clarity around?(e.g. With a therapist, mentor - optional to share)
14
Do you have any mental health issues (recent trauma, dissociative conditions, psychosis, substance abuse, addictions, etc.)
15
Are you currently taking any medications?(If yes, please specify)
16
Is there anything else related to your physical, emotional, or mental health that you feel may be important for me to know in order to support you safely in this work?(If relevant, this could include medical considerations, mental health support)
17
Have you ever used plant medicines, either past or present?(If yes, please specify - this helps me understand how to support you safely)
18
Are there any parts of your story you’d like me to know before we begin this work together?(Sharing is optional)
19
Any questions for me?
20
CLIENT AGREEMENTS

Please read the following carefully. Your signing and returning of this form acknowledge your understanding and acceptance of the terms of service.

I understand that the relationship with the Practitioner and any information shared with the Practitioner is considered confidential ("Confidential Information") and will not be disclosed except for the sole benefit of my self as the Client as necessary to perform any of the sessions in this container but not without my written consent.

I understand that my Practitioner will facilitate and provide support along the way but that, ultimately, I am responsible for my physical, mental and emotional well-being, and I will seek additional appropriate support if necessary.

I understand the teachings in this container affects people differently and that the results of each session may take some time to become fully apparent to me.

I take full responsibility for the level of effectiveness of this program. I acknowledge that it is my responsability to take appropriate action to integrate my sessions. My practitioner will support me with suggestions for aiding the integration process, however, whether I pursue these actions or not is entirely my own decision and responsibility.

I agree to disclose to my practitioner any current usage of prescription medication (including anti- depressants), and/or recreational drugs, as these may affect my results.

I understand that the sessions take place in a non-judgemental ‘safe space’ and that the content of our conversations and any work will be kept completely confidential unless a consent form is signed by the client.

I commit to paying for the container in full prior to the beginnging of the container, or to paying it off by the end of the agreed payment plan date (if paying by payment plan).

I agree to keep my practitioner notified of any medical information that would affect our work together.
21
Signature
Clear
22
Date
Date
Month
Day
Year
23
Terms & Conditions – Sovereign Woman* This field is required. By participating in this container, you acknowledge and agree to the following: Nature of the Work This container includes embodiment, breathwork, and practices that may involve emotional or physical release. It is not a substitute for medical, mental health, or therapeutic care. Personal Responsibility You are responsible for your own wellbeing and are encouraged to modify or pause any practice as needed. Health & Safety Disclosure You agree to share any relevant physical, emotional, or mental health considerations, including medications, to support your safe participation. Group Fit Participation requires a level of self-resourcing suitable for group work. I may suggest 1:1 sessions if the container is not the best fit at this time. Confidentiality Personal information and sharing within the container are confidential. Participants agree to respect the privacy of others. Consent By submitting this form, you confirm that you have read, understood, and consent to these terms, taking responsibility for your participation.
Please Select
Please Select
Yes
I agree to these Terms & Conditions
Should be Empty: