1:1 Consultation Form Landing Page

Curious About 1:1 Support

Welcome my love.

Thank you for your interest in the 1:1 membership.

Before we begin, it’s helpful for both of us to understand where you are right now, so we can see how this membership could best support you. Completing this short questionnaire allows us to email you the most relevant information about the membership and how it can help.

If you’re still unsure, you’ll also have the opportunity to book a free 30-minute call with Jess to talk things through. The questionnaire will automatically be sent to Jess after today, so she’ll be fully prepared to guide you if you choose to have that call.

The more details you provide, the more helpful we can be.

New Client

1:1 Membership Consultation Form.

Please be as open and detailed as you feel comfortable. This is a safe, nurturing space for you to share.
The more I understand about you, the more I can support you during your session.

First Name

Last Name

Phone Number

Emergency Contact

DOB

What is your occupation?

What is your relationship status?

Have you been diagnosed with any physical or mental health conditions? If yes, then please give details.

Are you currently receiving any therapy, counseling, or medical treatment? If yes, please give more details

Do you struggle with chronic stress or burnout?

Do you currently or previously struggle with anxiety or panic attacks?

Do you currently or previously feel emotionally numb or disconnected?

Do you have difficulty expressing or processing emotions

Do you have an past traumas affecting your daily life?

Are you currently taking any medications that affect your mood, emotional state or nervous system? If yes, please give details

Can you give a brief overview of what you are currently struggling with?

What are you hoping to achieve through our work together?

Have you practiced somatic movement, energy healing, breathwork, or other body-based therapies before? if yes, give details, if no, are you open to these modalities

Are you ready to invest your time, energy and finances into your journey? If yes, why now? and if no, whats holding you back?

Have you experienced significant trauma (such as ongoing abuse, assault, or a major life-threatening event) that you feel is still actively impacting your body, emotions, or sense of safety (especially in group settings?)

If you answered “Yes” or “Not sure,” I will reach out to schedule a consulation to ensure this work feels safe and supportive for you. Your wellbeing is my priority, and all responses are treated with care and confidentiality - please confirm belo

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Curious About 1:1 Support

Welcome my love.

New Client

1:1 Membership Consultation Form.

Join Our Free Trial