Healing & Support Services Intake & Registration Form

Healing & Support Services Intake & Registration Form

Welcome to A Mind Without Borders. This form helps us understand your needs so we can best support your healing, growth, and transformation. All information is confidential.
Contact Information

Please provide your contact details so we can reach you.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
City & State*
Preferred Method of Contact*

EmailPhoneText
Services Requested

Let us know which services you are interested in and how you identify.
Which service are you interested in?*

Individual CoachingEmotional Regulation SupportShadow WorkSpiritual Integration SessionsGroup Healing CircleProfessional DevelopmentOther
Are you:*

Seeking personal healingIn ministryA helping professionalIn leadershipExploring growthOther
Present Focus

Tell us more about your current focus and support needs.
What is bringing you here at this time?*
What areas would you like support with?*

Emotional regulationAnxiety / overwhelmLeadership stressTrauma processingSpiritual growthRelationship patternsConfidence / clarityIdentity developmentOther
Readiness & Commitment

Help us understand your readiness for growth and engagement.
On a scale of 1–10, how ready are you for change?*

1

2

3

4

5

6

7

8

9

10

1 is Not ready, 10 is Very ready
Are you willing to engage in reflection practices between sessions?*

YesNo
Agreement

Please read and acknowledge the following statement.
Signature*

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Date*

MonthDayYear
Date
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Healing & Support Services Intake & Registration Form

Contact Information

Services Requested

Present Focus

Readiness & Commitment

Agreement