Session Intake Form

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Session Intake Form

I’m excited and honored to be part of this journey with you! To better understand your goals and provide the best guidance, please take a moment to complete this brief survey.

If you need to reach me directly, please email heldnyc@proton.me.

Email *

Name (First Name/Last Name) *

Phone Number
*

City / State / Country
*

Age
*

Pronouns

Relationship Status
*

LinkedIn / Personal Website / Social Media Profile / Web Article About You (for verification purposes)
*

What is your biggest challenge right now? (physical, emotional, energetic, ...)
*

Past challenges? (physical, emotional, energetic, ...)

Spiritual or Religious Background / Experiences

Do you have any previous experience with tantric/somatic healing or embodiment practices? If so, tell me a little bit about it.

What are you most excited about achieving through our work together?
*

Are you looking for a deep shift and working together long-term or a single session-specific experience?
*

I'm looking to create long-lasting change in my life to live more with ease and in pleasure.

I'm just curious what it would feel like to fully be myself and be held in a non-judgmental space.

Have you ever been diagnosed with mental illness? If so what and when?

(All answers are kept strictly confidential and are for my own knowledge only to tailor a safe session.)

Do you have any questions about working together?

Is there anything else you would like me to know?

What is your availability for our initial video call (ca. 15 min) at least 24 hours before our session?

What is your availability to meet for our first session?

(ideally provide a few time frames or a general statement like "I’m available weekday daytimes")

By signing your name below, you agree to be coached, you take 100% responsibility for your satisfaction and experience in this and all future session/s, and you release the provider/coach from any liability for any possible legal matter you would wish to pursue at any point in the future.
*

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