Responder Reset— Intake Form

  • Intake Form

  • Welcome & Overview of Services

    Thank you for taking the time to complete this intake form. This information helps me understand your current experiences, stress levels, and support needs so I can best support you. I provide trauma-informed support using Brainspotting and nervous system regulation techniques. These approaches focus on helping the body process stored stress and trauma, regulate the nervous system, and improve overall functioning. This work is not traditional talk therapy and does not involve diagnosis or treatment of mental health disorders. Instead, it is a body-based, supportive approach designed to help you process experiences and build resilience.

  • Important Disclaimer & Consent

  • ✔ I understand that these services are not psychotherapy, counseling, or medical treatment
    ✔ I understand that no diagnosis or clinical treatment will be provided
    ✔ I understand that I am responsible for seeking licensed mental health care if needed
    ✔ I understand that if I am in crisis, I should call 911 or 988 immediately
    ✔ I understand that this service is trauma-informed support and nervous system regulation coaching only

  • Basic Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Emergency Contact

  • This contact will only be used in case of emergency where safety is a concern.
  • Format: (000) 000-0000.

  • Presenting Concerns

  • Nervous System + Symptom Check

  • Which of the following have you experienced? (check all that apply)*

  • Trauma / Exposure

  • Which of the following have you experienced? (check all that apply)*

  • Safety Support Check-In

    If you indicate active risk, I may refer you to appropriate licensed providers or emergency services.
  • Have you had thoughts about not wanting to be here anymore?*
  • Have you had thoughts about harming yourself?*
  • If yes, have you thought about how you might do that?*
  • If yes, have you ever acted on those thoughts in the past?*
  • Are you currently safe?*
  • Do you currently have an immediate support person when needed?*
  • Format: (000) 000-0000.

  • Coping + Support System

  • Do you feel supported?*
  • Are you currently working with a therapist or provider?*

  • Strength-Based Reflection

  • Readiness + Expectations

  • Are you open to body-based approaches, not just talking?*
  • Are you open to ongoing support if helpful?*

  • Final Consent + Signature

  • I confirm that the information provided is accurate to the best of my knowledge and that I understand the nature of the services being offered.

    (Please use your mouse or finger to sign below)

  • Date*
     - -
  • Should be Empty: