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
I acknowledge and agree
Basic Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Location (city / state)*
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Occupation / Department*
Years in Service*
Current Role*
If other, please explain:
Emergency Contact
This contact will only be used in case of emergency where safety is a concern.
Emergency Contact Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
City/State
Presenting Concerns
What’s been weighing on you lately?*
When did this start?*
What made you reach out now?*
Nervous System + Symptom Check
Trouble sleepingIrritability / angerFeeling on edge / hyper-alertEmotional numbnessIntrusive memories or imagesAvoidance of remindersFatigue / burnoutPhysical tension or painNone
Trauma / Exposure
Exposure to disturbing or critical incidentsFeeling betrayed by leadership or systemSituations where there were “no good choices”Regret about actions taken or not takenWitnessing death, violence, or tragedyNone
Safety Support Check-In

If you indicate active risk, I may refer you to appropriate licensed providers or emergency services.
YesNo
YesNo
YesNoN/A
YesNoN/A
YesNo
YesNo
Who is your immediate support person right now?
Support person phone number
Please enter a valid phone number.Format: (000) 000-0000.
Coping + Support System
What helps you cope right now?*
Who do you talk to when things are hard?*
YesNoSomewhat
YesNo
Strength-Based Reflection
What are you naturally good at?*
When do you feel most like yourself?*
What keeps you going right now?*
Readiness + Expectations
What are you hoping to get out of this work?*
YesNoUnsure
YesNoUnsure
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)
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Intake Form

Welcome & Overview of Services

Important Disclaimer & Consent

Basic Information

Emergency Contact

Presenting Concerns

Nervous System + Symptom Check

Trauma / Exposure

Safety Support Check-In

Coping + Support System

Strength-Based Reflection

Readiness + Expectations

Final Consent + Signature