Soul Centered Strength - Coaching Intake
Please fill out this intake form to help us understand your current situation, goals, and support needs.
You’re invited to share only what feels useful and appropriate. You may skip any question. You do not need to describe traumatic events in detail. This intake helps me understand your present-day patterns, needs, strengths, and capacity so our work can be paced with care. Coaching is not therapy, medical care, or crisis support.
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Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birthday
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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What’s bringing you here right now?
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What feels most stuck, heavy, or out of alignment right now? Share only what feels relevant.
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What have you already tried? What helped, even a little, and what felt missing or unsustainable?
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What are your top 1–3 goals for this next season?
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If this work goes well, what would be different in your life 6–12 months from now?
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On a scale of 0–10, how much stress are you carrying right now?
little or no stress
0
1
2
3
4
5
6
7
8
9
10
overwhelming stress
11
0 is little or no stress, 11 is overwhelming stress
How long has your current level of stress been present?
Less than 1 month
1–3 months
3–12 months
More than 1 year
It comes and goes
Unsure
Where or how do you notice stress in your body?
Jaw/face tension
Neck/shoulder tension
Chest tightness or shallow breathing
Solar plexus/stomach tension
Digestive changes
Headaches
Low-back or other pain
Fatigue/heaviness
Restlessness/agitation
Numbness or disconnection
Sleep disruption
Changes in appetite
Changes in libido
Other
I’m not sure
How is stress affecting your life right now?
Relationships
Parenting/family
Work/business
Physical health
Sleep
Mood
Focus/decision-making
Motivation/follow-through
Boundaries
Substance use or other coping habits
Spiritual connection/sense of meaning
Other
When stress rises, which responses feel familiar? These are protective nervous-system responses.
Fight/irritability or anger
Flight/busyness, overthinking, or difficulty slowing down
Freeze/feeling stuck or unable to act
Fawn/people-pleasing or losing touch with my needs
Shutdown/collapse or low energy
Numbness/disconnection
Hypervigilance or always scanning for problems
Perfectionism/control
I’m not sure
Other
What are the earliest signs that tell you you’re becoming activated, overwhelmed, or shut down?
When you become stressed or activated, how long does it usually take to return to a steadier state?
Minutes
Hours
The rest of the day
Several days
Longer
It varies
Unsure
What currently helps you feel safer, steadier, or more like yourself?
What tends to make things worse or feel too much, too fast?
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These questions are optional. You do not need to share details of what happened. The purpose is to understand context and pace our work safely.
Do you know your ACE (Adverse Childhood Experiences) score?
Yes
No
I’m not sure
Prefer not to answer
What is your ACE score?
0
1
2
3
4
5
6
7
8
9
10
Prefer not to answer
An ACE score is one piece of context, not a diagnosis or a measure of who you are. It does not capture protective relationships, resilience, or every form of adversity.
Without describing events, are there past experiences that still seem to affect your body, relationships, self-worth, sense of safety, or ability to trust?
Yes
No
Unsure
Prefer not to answer
What effects or patterns would be helpful for me to understand? Please focus on the present-day impact rather than details of the experience.
Have you previously worked with a therapist, counselor, somatic practitioner, recovery program, or other healing support?
Currently
In the past
No
Prefer not to answer
What approaches were helpful, unhelpful, or important for me to know?
Are there any known triggers, topics, touch, breath practices, body-based exercises, or coaching approaches you would like me to avoid or approach carefully?
When you feel overwhelmed, do you ever lose time, feel unreal, feel outside your body, or have difficulty staying present?
Never
Rarely
Sometimes
Often
Unsure
Prefer not to answer
Are you currently experiencing a crisis or any concern about your immediate safety that may need support from a licensed mental-health or medical professional?
No
Yes
Unsure
Prefer not to answer
This form is not monitored for urgent support. If you may be in immediate danger, call 911. In the U.S., call or text 988 for immediate crisis support.
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Who or what is part of your support system right now?
Partner/family
Friends/community
Therapist/counselor
Physician or medical team
Spiritual community
Peer-support or recovery group
Movement/exercise
Time in nature
Creative practice
Other
I don’t feel I have reliable support right now
What strengths, practices, relationships, or qualities have helped you through difficult seasons?
How would you like me to respond if I notice you becoming overwhelmed or disconnected during a session?
Slow down
Pause and orient to the room
Invite a breath or grounding practice
Ask what I need
Offer choices
Take a break
Name what you notice gently
I’m not sure yet
Other
What pace feels most supportive right now?
Gentle and spacious
Steady with some challenge
Direct and action-oriented
I’m not sure—help me discover it
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What protective patterns or habits tend to pull you off track or make follow-through difficult? Examples might include overcommitting, perfectionism, avoidance, people-pleasing, shutdown, or trying to do everything alone.
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What kind of support, accountability, or coaching helps you the most?
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What might help you feel one point more ready, supported, or resourced?
By submitting, I understand that coaching is not psychotherapy, medical treatment, or crisis care. I can choose what I share and can ask to pause, slow down, or change direction at any time.
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On a scale of 1–10, how ready are you to make meaningful changes right now?
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Not Ready
1
2
3
4
5
6
7
8
9
Completely Ready
10
1 is Not Ready, 10 is Completely Ready
Why did you select that number?
*
What is the best time for a discovery call?
*
Submit Intake Form
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