The Shift Intake

Name *

Email *

Age *

Where do you currenty live?

For climate, local services and time zone reference.

What is your primary issue or focus right now? *

What do you want to shift?

What do you feel are the biggest obstacles to making the changes you know would help?

This might include time, energy, resources, willpower, or even confusion about where to start.

What would feel like the most supportive thing in the world to you right now?

Even if it’s unrealistic or impossible, name it.

Give me an overview of your current diet.

Do you cook for others? Eat out often? Enjoy cooking for yourself? What’s your kitchen pantry like? Just let it rip.

What are your current self-care practices, if any

Include how often, how integrated into your daily routine, and anything else that feels important.

Any current medications or ongoing treatments? What are you trying right now?

Please share anything relevant.

What kind of shift would feel exciting right now?

One real, grounded shift that would help you feel momentum.

How would you describe your self-healing style?

I need accountability — otherwise I drift

I need small, doable steps or I’ll freeze

I already have strong routines — just want to go deeper

I’m not sure yet — that’s part of why I’m here

Have you experienced Rebirthing Breathwork before?

Or any holotropic connected breathing sessions

YES

NO