Payment Confirmed.
Your consultation container is secured.
To finalise your slot and allow me to map your nervous system, please complete your clinical details below.

Ancestral Healing Therapy Intake & Assessment Form

Instructions for Client:

Section 1: Client Demographics & Confidentiality

Full Legal Name (as given at birth, if known):

First

Middle

Last

Date of Birth & Age

or Stability System

Current Physical Location (City, Region, Country):

Your Local Time Zone (e.g., GMT, EST, PST, AEST):

Please enter your email, so I can follow up with you.

Mobile / WhatsApp Number (with Country Code):

Emergency Contact (Name & Number): (Required for safety protocols)

GP / Medical Practice Name & City: (Standard requirement for UKCP-accredited deep clinical work)

Section 2: Pathway & Container Selection – Please select your chosen pathway:

The Ancestral Healing Foundation (£620)- Mandatory 3-hour entry point for all new clients (1-Hour Clinical Consultation + 2-Hour Deep Dive applied intervention).
Container 1: Lineage Trauma Resolution (£830) – 2 x 2.5-Hour Deep Dives (Returning clients only).
Container 2: Ancestral Transformation (£1,260) – 3 x 2.5-Hour Deep Dives (Returning clients only).

Section 3: Systemic Lineage Mapping & Transgenerational Entanglements

2. Lineage Focus: Which branch of your lineage feels heaviest or most present in this work right now?

Maternal Line (Mother, Grandmother, female ancestors)
Paternal Line (Father, Grandfather, male ancestors)
Both Lines / Systemic Intersection
Unknown / Adoptive Lineage dynamics

3. Historical & Lineage Events:

4. Somatic & Nervous System Indicators:

5. Psychological Readiness & Previous Interventions:

5. Current Support Team:

6. Healing & Development History:

7. Process & Integration Preferences

Section 4: Clinical Governance & Contraindications

Do you have a personal history of, or are you currently diagnosed with:

Schizophrenia, Psychosis, or Bipolar Disorder?
Severe Clinical Depression or active psychiatric crisis?
Are you currently under the active care of a psychiatrist, or receiving clinical mental health treatment?

Section 5: Safety & Stability Check

Safety Disclaimer: This is a high-level therapeutic practice, not an emergency crisis line.

Because this work involves deep somatic and energetic processing, it requires a foundation of current stability. Are you currently navigating an acute crisis or active addiction that requires immediate emergency intervention?

No, my system is currently stable enough to engage in deep, transformative work.
Yes, I am currently navigating an acute mental health crisis. (If selected, please get in touch with emergency services as this therapeutic container is not a substitute for crisis intervention).

Section 6: Alignment, Investment & Legal Consent

Terms of Engagement & Therapeautic Container Policy:

1. The Fixed Container Policy:

3. Ending the Work (The Closing Phase):

2. Financial Commitment:

4. Communication Boundaries:

5. Professional Ethics & Privacy:

Section 7: Clinical Safety & Transpersonal Boundaries & Financial Consent & Container Commitment. (Please review and check each statement to confirm your understanding):

UKCP Clinical Safety: I understand that Ancestral Synthesis is an intensive clinical and somatic-energetic process. While this work transcends linear time, it requires psychological stability and active nervous system regulation.
I understand that this practice is dedicated to deep, clinical containers rather than short-term ‘check-in’ sessions.
Foundation Structure (3 Hours): I understand that all new clients begin with the 3-hour Foundation (£620) to ensure thorough clinical mapping before moving directly into field intervention.
Safe Space Consent: I commit to attending all sessions from a private, safe, and quiet location where I will not be interrupted, ensuring the confidentiality and depth of our clinical work.
Financial Commitment & Policy: I acknowledge that all fees are paid in full to secure my placement in the diary. I understand that for all single and container sessions, there is a strict no-refund, no-cancellation, and no-postponement policy. Once a session is booked, the time is dedicated exclusively to my clinical work and cannot be moved or refunded.
Not Crisis Intervention: I confirm I am not currently experiencing active suicidal ideation, psychosis, or an acute psychiatric crisis requiring emergency secondary care.
Medical Non-Advice: I understand that while we address ancestral themes, this is a therapeutic service and not a substitute for medical care from a GP or specialist.
Investment Readiness: I am ready to commit to a premium, specialised clinical container and have the resources to invest at this level of depth.
Acknowledgement: By proceeding with your booking and payment, you are agreeing to enter this therapeutic container under these terms. You are acknowledging that this structure is in place to support your highest level of performance and transformation.

Section 8: Final Submission

Date