Intake & Payment

Pathway 6: Clinical Reiki & Energy Healing
Price range: £150.00 through £900.00

Reiki Healing
Select options This product has multiple variants. The options may be chosen on the product page
Pathway 2: Intertwined Specialisms
Price range: £390.00 through £4,200.00
Clinical Therapy Intake Form
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Clinical Therapy Intake & Screening Form
Instructions for Client:
Section 1:
Name
First
Last
Email
Please enter your email, so I can follow up with you.
Telephone Number
& Medication safety
Age
Location and Time Zone
Emergency Contact (Name & Number): (Required for clinical safety protocols)
Section 2: Clinical Specialisms Which area(s) of clinical focus are you seeking support for? (Select all that apply):
Inner Child Healing: (Attachment wounds, childhood relational trauma, and core belief restructuring).
Neurodivergent Support: (ADHD/Autism sensory overload, unmasking, and burnout prevention).
Neuro-Hormonal Clinical Support (Addressing the intersection of trauma/neurodivergence with adrenal burnout, PMDD, perimenopause, or chronic fatigue).
Advanced Trauma Resolution: (C-PTSD, flashbacks, ancestral imprints, or dissociative patterns).
Narcissistic Abuse Recovery: (Cognitive dissonance, recovery from high-conflict dynamics, and rebuilding the self).
Depth of Focus Selection:
Tier 1: Complex Singular Focus— I need deep, specialised healing focused primarily within one specific domain.
Tier 2: Complex Intersectional Focus— My situation is highly layered (e.g., Trauma + Burnout + Identity Loss), requiring multiple specialisms woven together.
Section 3: Your Somatic & Medical Story
The Somatic Narrative:
Medication & Diagnoses:
Clinical History:
Section 4: Safety & Stability Check
Clinical Safety Disclaimer:
If you are currently in an emergency, fear for your physical safety, or are in a mental health crisis, please get in touch with your local emergency services, your GP, or a crisis hotline (such as the Samaritans or a Local Domestic Abuse Hotline) immediately.
Because this work involves deep somatic and energetic processing, it requires a foundation of current stability.
Select below
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 practice is not an emergency service).
Section 5: Alignment & Investment.
Clinical Assessment Selection:
Specialism Clinical Assessment (90-minutes): £290 (Focusing on one primary area)
Intersectional Clinical Assessment (90-minutes): £390 (Focusing on multiple layered specialisms)
Terms of Engagement & Clinical Container Policy:
1. The Fixed Container Policy:
2. Financial Commitment:
3. Ending the Work (The Closing Phase):
4. Communication Boundaries:
5. Professional Ethics & Privacy:
6. Acknowledgement:
Practice Boundaries, Financial Consent & Container Commitment. (Please check all):
I understand that this practice is dedicated to deep, clinical containers rather than short-term 'check-in' sessions.
Financial Commitment & Policy: I acknowledge that all fees are paid in full to secure my placement in the diary. I understand that for all assessments 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.
Assessment Requirement: I am aware that all clinical pathways begin with a mandatory 90-Minute Assessment to map my nervous system and determine my clinical roadmap.
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.
Medical Non-Advice: I understand that while we address neuro-hormonal 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.
Section 6: Final Submission
Date
GDPR Agreement
I consent to having this website store my submitted information so they can respond to my inquiry.
Select options This product has multiple variants. The options may be chosen on the product page
Pathway 3: Specialist Clinical Supervision
Price range: £150.00 through £480.00
Clinicial Supervision Intake Form
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Section 1:
Name
First
Last
Professional Title:
Professional Body & Registration Number: (e.g., UKCP, BACP, NCS, etc.)
Years in Practice:
Primary Modality: (e.g., Psychodynamic, Integrative, Hypno-Psychotherapy, etc
Email
Please enter your email, so I can follow up with you.
Telephone Number
Age
Location and Time Zone
Current Practice Status:
Senior/Established Practitioner
Emerging Specialist/Neurotherapist
Neuro Student / Trainee
Other
Section 2: Practice Context & Complexity
Average Weekly Caseload Volume:
Clinical Specialisms (Select all that apply):
Complex Trauma (C-PTSD)
Narcissistic Abuse & High-Conflict Dynamics
Neurodivergent (ADHD/Autism/AuDHD) Affirming Care
Somatic/Body-Based Therapy
Energy Psychotherapy / Energy Medicine
Hormonal/Menopausal Mental Health
Other
The Complexity Map:
Section 3: The Multidimensional & Neuro-Affirming Lens Identifying the "Neurospicy" and Energetic fit.
Neuro-Identity: Do you identify as a Neurodivergent (ND) or Highly Sensitive (HSP) practitioner?
Yes
No
Exploring/Unmasking
Energetic Integration: Do you currently integrate Energy Medicine (e.g., EFT, Biofield work) into your clinical practice?
Yes, it is a foundational part of my work.
I am beginning to integrate it and need clinical oversight.
No, but I am open to the "energy-informed" lens in supervision.
Somatic Tracking: On a scale of 1-10, how aware are you of your own somatic countertransference (body responses) during sessions?
Selected Value: 0
Section 4: Supervision Requirements
Desired Supervision Structure:
Complex Case Deep Dive (90 Mins): £350
Extended Clinical Review (120 Mins): £480
Student/Trainee Container (90 Mins): £150
Specialist Group Supervision (2 Hours): £160-£240
Supervision Goals:
Section 5: Safety & Professional Responsibility
Multidimensional own Zone
Section 6: Practice Boundaries & Clinical Commitment
1. The Fixed Container Policy:
2. Financial Commitment:
3. Ending the Supervisory Relationship:
4. Communication Boundaries:
5. Professional Ethics:
Practice Boundaries & Clinical Commitment
Checkboxes
Financial Commitment & Policy: I acknowledge that all fees are paid in full to secure my placement in the diary. I understand that there is a strict no-refund, no-cancellation, and no-postponement policy. Once a diary slot is secured, it cannot be moved or refunded, and I am responsible for the full fee regardless of attendance.
Ethical Framework: I confirm that I am currently a member of a professional body (e.g., UKCP, BACP, or equivalent) and that I operate in accordance with its ethical guidelines and hold my own professional indemnity insurance.
Safety & Crisis Acknowledgement: I understand that my supervisor provides clinical oversight and is not an emergency service. I take full professional responsibility for the safety of my clients and will follow my own professional body’s safeguarding protocols in the event of a crisis.
Closing Phase Agreement: I agree to provide the required notice period (4 weeks or one full session) should I wish to end the supervisory relationship, to allow for an ethical closing process.
Confidentiality & GDPR: I understand that all client material presented in supervision will be anonymized to protect client identity, and I consent to my data being stored in accordance with UK GDPR.
Acknowledgment
Section 7: Final Submission
Date
GDPR Agreement
I consent to having this website store my submitted information so they can respond to my inquiry.
Select options This product has multiple variants. The options may be chosen on the product page
Pathway 1: Single Specialism
Price range: £290.00 through £3,000.00
Clinical Therapy Intake Form
Please enable JavaScript in your browser to complete this form.
Story Terms (Select
Clinical Therapy Intake & Screening Form
Instructions for Client:
Section 1:
Name
First
Last
Email
Please enter your email, so I can follow up with you.
Telephone Number
Age
Location and Time Zone
Emergency Contact (Name & Number): (Required for clinical safety protocols)
Section 2: Clinical Specialisms Which area(s) of clinical focus are you seeking support for? (Select all that apply):
Inner Child Healing: (Attachment wounds, childhood relational trauma, and core belief restructuring).
Neurodivergent Support: (ADHD/Autism sensory overload, unmasking, and burnout prevention).
Neuro-Hormonal Clinical Support (Addressing the intersection of trauma/neurodivergence with adrenal burnout, PMDD, perimenopause, or chronic fatigue).
Advanced Trauma Resolution: (C-PTSD, flashbacks, ancestral imprints, or dissociative patterns).
Narcissistic Abuse Recovery: (Cognitive dissonance, recovery from high-conflict dynamics, and rebuilding the self).
Depth of Focus Selection:
Tier 1: Complex Singular Focus— I need deep, specialised healing focused primarily within one specific domain.
Tier 2: Complex Intersectional Focus— My situation is highly layered (e.g., Trauma + Burnout + Identity Loss), requiring multiple specialisms woven together.
Section 3: Your Somatic & Medical Story
The Somatic Narrative:
Medication & Diagnoses:
Clinical History:
Section 4: Safety & Stability Check
Clinical Safety Disclaimer:
If you are currently in an emergency, fear for your physical safety, or are in a mental health crisis, please get in touch with your local emergency services, your GP, or a crisis hotline (such as the Samaritans or a Local Domestic Abuse Hotline) immediately.
Because this work involves deep somatic and energetic processing, it requires a foundation of current stability.
Select below
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 practice is not an emergency service).
Section 5: Alignment & Investment.
Clinical Assessment Selection:
Specialism Clinical Assessment (90-minutes): £290 (Focusing on one primary area)
Intersectional Clinical Assessment (90-minutes): £390 (Focusing on multiple layered specialisms)
Terms of Engagement & Clinical Container Policy:
1. The Fixed Container Policy:
2. Financial Commitment:
3. Ending the Work (The Closing Phase):
4. Communication Boundaries:
5. Professional Ethics & Privacy:
6. Acknowledgement:
Practice Boundaries, Financial Consent & Container Commitment. (Please check all):
I understand that this practice is dedicated to deep, clinical containers rather than short-term 'check-in' sessions.
Financial Commitment & Policy: I acknowledge that all fees are paid in full to secure my placement in the diary. I understand that for all assessments 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.
Assessment Requirement: I am aware that all clinical pathways begin with a mandatory 90-Minute Assessment to map my nervous system and determine my clinical roadmap.
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.
Medical Non-Advice: I understand that while we address neuro-hormonal 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.
Section 6: Final Submission
Date
GDPR Agreement
I consent to having this website store my submitted information so they can respond to my inquiry.
Select options This product has multiple variants. The options may be chosen on the product page

Pathway 6: Clinical Reiki & Energy Healing

Pathway 2: Intertwined Specialisms

Pathway 3: Specialist Clinical Supervision

Pathway 1: Single Specialism