INTAKE FORM | HACKING SIMPLICITY


HELLO BEAUTIFUL!

Below are questions for you to answer so I can get to know a little more about you.


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Email *

What’s your first & last name?

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When were you born (mm/dd/yyyy)?

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Where were you born (city, state, country)?

What time were you born? What is your source (i.e. birth certificate, hospital record)?

Gender assigned at birth (AMAB/AFAM)? What gender do you identify with? What pronoun do you use (he/she/they)?

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Where did you grow up (city, state, country)?


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Where do you live now (city, state, country)?


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What major events shaped who you are?  

{For example, birth of siblings, your family moving to a new place, an accident, falling in love and other important times. Include your age with each event.}

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What do you want out of these sessions?

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Are you currently seeing a therapist, counselor, healer, psychologist, psychotherapist or other professional?

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If yes, list the type of practitioner and how long you have been working with them.

Working with other practitioners

When working with an IST practitioner (that’s what I am) over a period of time, there is a process that involves your body of energy and your timeline. I will be holding these both for you. If you go to a number of different practitioners (IST, acupuncturist, astrologist, healer, reiki, palm reader or whatever else is out there) at once, it can wrongly color your energy and trajectory. As the saying goes, “Too many cooks spoil the broth.”

In order that your process is held with the utmost integrity, let’s chat about how you can get the most out of your personal development. If you want to work with other practitioners, it may be that you and I work together after your time has ended with them or that we work together for three months and then you see them afterward. Feel what is right for you.

Are you on any medications? If yes, please list the name of the medication(s), what you are taking it for, when you started taking it and what was going on in your life when you started taking it.


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Do you do recreational drugs/plant medicines? If yes, how frequently? Please include the name, when you started taking it and what was going on in your life when you started taking it.



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Please note

This technique doesn’t mix well with recreational/psychedelic drugs or medicinal substances/plant medicines of any kind.  Please make sure you don’t consume alcohol 48-hours before a session and that you do not use marijuana or other mind altering substances at least 6 weeks before we start our sessions. No hard drugs ever. 

Do you have a daily meditation practice?

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If you have social profiles, please list the URLs here.

Personal website: www.somethingcool.com

YouTube/Vimeo video links: youtube.com/

Linkedin: www.linkedin.com/in/

Instagram: www.instagram.com/


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Is there anything else you’d like to tell me before we start our sessions together?

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Working with me

I’m super excited to do sessions with you!  

What I’ve noticed is my clients who completely let go into the process make the biggest shifts. Around session 6 to 8, you will start to feel things taking place. As a result, you may experience more relaxation, less anger, and more strength, for example. Sometimes negative feelings will become louder before they are de-charged. That is totally okay. Welcome actually. This work is for the ambitious and strong. It brings clarity so you can be the best at everything you do.

You always have the option to say “STOP” during a session if you don’t want to see or feel something.  I will stop and ask you if you really mean stop.  If you do, we will stop the session immediately.  No questions asked.

Last but not least, I make mistakes. I forget. I don’t always properly communicate what I see. I’m imperfect. Yet I strive to rest on Connection so my humanness doesn’t get in the way of giving profound sessions. Don’t listen to my words but rather feel the space behind what I say. 

Feel free to text or email me updates between sessions. This open communication helps maintain a flow.

Commitment

One of the biggest things that makes a difference in your transformation is commitment. It is extremely beneficial to do a series of sessions regularly (once or twice a week) for three months as opposed to doing sporadic sessions over the course of a year. A momentum will click in and you won’t have to work as hard. The more you commit to your process, the more Connection can gear in and help you. This work transforms lives!

Practical Things

Please wear comfortable clothing.  

Refrain from drinking caffeinated beverages the morning and afternoon of our session. 

Please don't drink alcohol for 48-hours prior. Don't do recreational drugs (marijuana, psychedelics, ayahuasca, hard drugs or any other mind altering substance) for 6 weeks beforehand. This is super important, as it can have serious negative effects on both of us. If you can't live without mild altering substances, let’s work together once you are clean.

If we are meeting in person, please do not wear any perfume, aftershave or other personal products (like shampoo & condition) with synthetic smells.

When booking sessions, I’ll communicate the time in Pacific Time (California) no matter where you are in the world. 

Please give 24-hour notice if you need to cancel your appointment. We are working at an energetic level and it is not good for either one of us if a cancellation is made at the last minute.

If you have to pause your sessions for any reason, please inform me by phone, not by text or voice message. 

It’s about honoring your personal growth and development.

Terms & Agreement

By working together, you agree to:

  • show up fully for your sessions, engage openly, and do the inner work required for transformation.

  • communicate honestly if something isn’t working so we can adjust as needed.

  • honor our time together by being on time and present.

  • respect the energy of this work by maintaining a clean, focused and drug-free mindset.

  • recognize this work is not medical treatment but rather a collaborative process aimed at personal and professional growth.

Confidentiality

Everything you share in this document stays between us. I will not share it with anyone. 

Thank you for taking the time to complete this.

Talk soon,

AnneMarie
annemarieinsf@gmail.com

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