• Private Intensive Pre-Screen

    Please complete this short pre-screen before your private intensive. If anything in your responses suggests that a deeper conversation would be helpful, we will discuss it privately before confirming the session.

  • Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Brief Screening

  • Do you have any current medical conditions, symptoms, or health concerns that may affect safe participation?*
  • Are you currently taking any prescription medications, over-the-counter medications, or supplements that may need to be reviewed before participation?*
  • Do you have any current or past mental-health concerns or experiences that should be discussed before participation?*
  • Are you currently experiencing significant stress, grief, instability, or emotional overwhelm that may affect your readiness?*
  • If needed, are you willing to discuss relevant medical, psychological, or medication-related concerns privately before participation?*
  • Do you understand that this work is not a substitute for medical or psychiatric care?*

  • Review and Confirm

  • I have read the information above and answered these questions honestly and to the best of my knowledge. I understand that additional private screening may be requested before participation is confirmed. I also understand that this work is not a substitute for medical or psychiatric care

  • Date*
     - -
  • Should be Empty: