Neurodivergent Support Client Intake

Emergency Contact (Name)*

Emergency Contact Number*

Emergency Contact Relationship*

What brings you to Neurodivergent Support? (Please share briefly what you'd like to explore or work on.)*

What are your current goals for this work together?*

Do you have prior experience with therapy, coaching, or personal development work?*

If yes, briefly describe:

How would you describe your / your child's relationship to your body and emotions?*

What are your / your child's strengths, interests, and joys?*

What are your / your child's challenges or areas of difficulty?*

Do you / your child have any concerns, fears, sensitivities or boundaries that you would like me to be aware of as we work together?*

Have you / your child experienced trauma, stress, or events that have impacted your / their relationships, behavior and/or emotional regulation?*

If yes, please share only what feels comfortable:

Do you / your child have any physical conditions, injuries, or sensitivities that I should know about?*

Do you / your child currently participate in any form of mindfulness, movement, creative play or bod-based practices?*

Do you have specific modalities or practices you / your child are interested in exploring (e.g., gentle touch, guided imagery, movement, sensory play, etc.)?*

Are there any specific boundaries, accommodations, or preferences that you / your child like to share?

What are you / your child's expectations or hopes for our sessions together?*

I understand that Neurodivergent Support Coaching may include verbal and experiential practices designed to help me / my child connect with my / their body, emotions, and desires. I understand that my / my child's participation is voluntary, and I can set boundaries or stop at any time.*