Secure Base Relational Healing Container Application

  • Secure Base Relational Healing Container Application

    APPLICATION

  • Welcome!

    This application is the first step to joining the Secure Base 12-Week Relational Healing Container. Please answer honestly and completely. This program is designed for relational healing and attachment support, not therapy or crisis intervention.Completing this form does not guarantee acceptance. Spaces are limited to 3 participants per cohort.

  • Personal Information

  • Format: (000) 000-0000.

  • Multiplicity & Context

  • Do you experience multiplicity (e.g., multiple internal identities or parts)?*
  • Are you currently seeing a therapist, coach, or counselor?*
  • Do you have supportive people you can reach out to outside this container?*
  • Are you currently experiencing any active crisis, safety concerns, or situations requiring immediate support?*

  • Goals & Intentions

  • Readiness & Commitment

  • Can your system tolerate structured gaps in support (defined messaging days, response window, no weekend messages)?*
  • Are you willing to practice exercises and reflection prompts outside live sessions?*
  • Can you and all your internal parts (if relevant) respect container communication boundaries?*
  • Can you commit to the 12-week schedule, including group calls and individual sessions?*

  • Optional Additional Information

  • Logistics & Acknowledgements

  • Thank you for completing the application form! We will review your responses and email you regarding acceptance, scheduling, and payment instructions. Spaces are limited to 3 participants, so early submission is encouraged.

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