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.*