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
Name*

First NameLast Name
Email*
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Time Zone:*
Multiplicity & Context
Do you experience multiplicity (e.g., multiple internal identities or parts)?*

yesnounsure
If you answered "yes," please describe any relevant context, communication style, or considerations for the container.
Are you currently seeing a therapist, coach, or counselor?*

yesno
If you answered "yes," please specify.
Do you have supportive people you can reach out to outside this container?*

yessomewhatno
Are you currently experiencing any active crisis, safety concerns, or situations requiring immediate support?*

yesno
If you answered "yes," please briefly describe.
Goals & Intentions
What brings you to this container?*
What are your top 2–3 goals for this 12-week program?*
How do you hope you and/or your internal parts will experience support during this program?*
Readiness & Commitment
Can your system tolerate structured gaps in support (defined messaging days, response window, no weekend messages)?*

yesunsureno
Are you willing to practice exercises and reflection prompts outside live sessions?*

yesunsureno
Can you and all your internal parts (if relevant) respect container communication boundaries?*

yesnounsure
Can you commit to the 12-week schedule, including group calls and individual sessions?*

yesunsureno
Optional Additional Information
Anything else to share about yourself or your internal system (if relevant) that would help participation?
Logistics & Acknowledgements
Confirm understanding: This program is coaching/relational support, not therapy, and participants must maintain external supports.*

I understand and agree
Confirm understanding: The container has a fixed 12-week duration, structured sessions, and messaging boundaries.*

I understand and agree
Confirm understanding: Completing this intake form does not guarantee acceptance.*

I understand and agree
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.
Should be Empty:

Secure Base Relational Healing Container Application

Welcome!

Personal Information

Multiplicity & Context

Goals & Intentions

Readiness & Commitment

Optional Additional Information

Logistics & Acknowledgements