Discovery & Intake Form

Welcome. There is no rush here.

The intention of these questions is not to analyze or diagnose you, but to help me better understand your history, your current support, your nervous system patterns, and what you are quietly longing to receive.

This process is collaborative, gentle, and paced slowly. There is no “right way” to heal, and no pressure to share more than feels comfortable.

You Are Welcome Here, Exactly As You Are

Many people arrive carrying overwhelm, disconnection, exhaustion, grief, longing, or simply a quiet sense that something important is missing. Whatever you are bringing today, it belongs.

Take a breath. Find a quiet moment. Answer as openly and honestly as feels right.

Your Intake

Answer the Questions Below

The form below gently walks through basic information, current support, your history, nervous system patterns, and what you are hoping to receive from our work together.


Your answers are received with care and complete confidentiality.

What This Form Helps Us Explore Together

Each section of the form is an invitation, not an interrogation. Here is the gentle terrain we will move through.

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Your Story & Support

Basic information and the people, practices, and practitioners currently walking beside you.

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Your Body & Nervous System

Patterns of overwhelm, shutdown, sleep, energy, and what your body has been quietly carrying.

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Your Earliest Beginnings

What you know (or sense) about your conception, birth, and early childhood environment.

A Note Before You Begin

There is a part of you that has been working very hard to manage, protect, and hold everything together. This form is one of the first places that part can quietly set something down.

You don't need to have the right words. You don't need to remember everything. Whatever surfaces is exactly enough for where we are starting.

PART 1 - Basic Infomration

PART 2 — Current Support & Health

Are you currently working with any of the following?
If yes, briefly describe
Are you currently taking any medications?
Do you experience any ongoing physical symptoms, chronic pain, tension, fatigue, or health concerns?
How would you describe your current sleep patterns?
Have you previously explored any of the following?

PART 3 — What Brings You Here?

What is the main reason you are seeking support at this time?
What feels most difficult, painful, confusing, or “loud” in your life right now?
What are you hoping to receive or experience through this work?
If things began moving in a positive direction, what would feel different in your daily life?
What helps you feel emotionally safe and supported with another person?

PART 4 — Early Life & Relational Experiences

What do you know about your early life, birth, or family environment? (You may leave blank if unknown.)
Were there any significant separations, medical procedures, hospitalizations, losses, or major stressors during your early childhood?
How would you describe your relationship with your primary caregivers growing up?
Did you generally feel: (Check any that resonate)
Other:

PART 5 — Stress & Nervous System Patterns

When you are stressed or overwhelmed, what do you notice happens most often? (Check any that apply)
Other:
How connected do you feel to your body and emotions most of the time?
Are there certain emotions or experiences that feel especially difficult to access or express?

PART 6 — Session Preferences & Readiness

Which approaches feel most supportive or interesting to you? (Check any that apply)
Do you generally prefer sessions that are:
Is there anything that tends to make you feel emotionally unsafe, overwhelmed, pressured, or shut down in healing spaces?
PART 7 — Intentions & Expectations
This work often unfolds gradually through safety, consistency, awareness, and nervous system support rather than dramatic breakthroughs.
What does a “gentle but meaningful” healing process look like to you?
Sessions may feel 'quiet' or 'boring' at times. We may spend 20 minutes just settling your breath before we even speak. Transformation happens in whispers, not shouts. 
If we were to move at the “speed of safety,” what is one feeling, quality, or experience you would like more of in your life?
What is one feeling, quality, or experience you would like more of in your life?
At some point, I may miss a cue, say the wrong thing, or not move as fast as you want me to. This isn't a failure of the work; it’s a vital part of it. These moments are opportunities to practice 'safe repair', something many of us didn't get as infants.
Is there anything else you would like me to know before we begin?
Consent & Acknowledgment I understand that these sessions are intended for personal growth, nervous system support, somatic awareness, and relational healing, and are not a substitute for medical, psychological, or psychiatric care.
draw your signature

Once You Submit

Your responses come directly to me. I read each one personally, with care, before our first time together. If anything important arises between now and then, you are always welcome to reach out.

Questions? Reach out to Julia at julia@cosmicbirth.com