Client intake form Name * First Name Last Name Email * Phone * (###) ### #### Instagram Handle Example: www.instagram.com/@freequenseeunlmtd_ http:// What truth have you never said out loud -- but you WANT to be reflected back to you? * What feels stuck, misaligned, or misunderstood in your voice or identity right now? * If this session gives you one sentence that shifts everything—what do you hope it reflects? * Which of these feels most true right now? * I feel powerful but hidden I’ve outgrown my message I'm performing clarity I've lost my softness I'm tired of explaining myself I don't know -- I just feel something's ready to shift Do you agree to enter this session with openness, emotional honesty, and respect for silence, sensation, and stillness as valid responses * Yes No Will you be in a private, safe space during the session? * Yes No THERAPY DISCLAIMER — I acknowledge that this session is not therapy, diagnosis, or medical care. This is an intuitive reflection and energetic container designed for personal insight and inner clarity. I understand that I am responsible for my own emotional safety, integration, and meaning-making. (Initial Below) * TERMS & CONDITIONS AGREEMENT By booking this session, I agree that: • I am mentally and emotionally stable enough to participate in deep reflection • I will not hold the facilitator responsible for any outcomes or interpretations • I understand no guarantees, advice, or outcomes are promised • I agree not to record, share, or replicate the session experience without consent • I will not request refunds after the session is delivered unless agreed upon beforehand (Please initial below) * Consent: I have read and agree to the therapy disclaimer, terms, and mutual NDA. I am ready to enter the Deep Mirror with openness and trust. Please type your full name and date for consent * Thank you!
