Neuro-Somatic Energy Coaching & Insight Consult

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Neuro-Somatic Energy Coaching
Price range: £550.00 through £8,100.00
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Neuro-Somatic Energy Coaching Intake & Screening Form
Welcome
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Instructions for Client:
Section 1: Professional Background & Identification
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 safety protocols)
Section 2: The Gateway: Which coaching pathway are you seeking to enter?
Neuro-Somatic Energy Coaching (Blueprint) - High-level regulation, nervous system rewiring, and energetic field alignment for peak performance.)
Neuro-Somatic Hormonal Energy Coaching (Rebirth) - A sophisticated blend of endocrine health, neuro-somatic tools, and energy psychology for metabolic and hormonal peace.)
Section 3: The Deep Dive
Readiness Scale:
Number Slider
Selected Value: 0
Section 4: Your Somatic Story & Support Ecosystem
The Somatic Narrative: Traditional coaching often operates purely in the mind. My practice utilises active neuro-somatic rewiring and energy psychology. Please briefly describe how your history is currently impacting your physical body, nervous system, or energy levels (e.g., chronic exhaustion, hypervigilance, physical tension, hormonal flares).
Current Support Team: Are you currently working with any other practitioners (e.g., GP, Endocrinologist, Nutritionist, or Therapist)? This helps me ensure our work is complementary to your existing care.
Healing & Development History: Have you previously engaged in coaching, therapy, or energy healing? If yes, what was your experience with those modalities?
Narrative: describe Name
Section 5: Hormonal & Metabolic Focus
Bio-Markers: Are there specific hormonal or metabolic concerns you are currently navigating? (e.g., Thyroid issues, PCOS, Perimenopause, Adrenal Fatigue, Chronic Fatigue Syndrome, or Cycle Irregularities).
Section 6: Safety & Stability Check
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 contact your local emergency services or crisis support line, as this coaching container is not a substitute for crisis intervention.)
Section 7: Alignment, Investment & Legal Consent
Pathway Investment Confirmation:
Professional Coaching Assessment (90-minutes): £550 (This mandatory assessment maps your nervous system and determines your bespoke coaching roadmap.)
Practice Boundaries & Consent: (Please check all to confirm)
Container Commitment: I understand that this practice is dedicated to deep, multidimensional energy coaching 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.
Medical Non-Advice Disclaimer: I understand that Neuro-Somatic Energy Coaching is not a substitute for professional medical advice, diagnosis, or treatment. I acknowledge that this is a coaching relationship and not a medical or clinical endocrine service.
Environmental Consent: I commit to being in a private, quiet, and safe space for my 90-minute assessment, where I can move or sit comfortably and speak freely without interruption.
Investment Readiness: I am ready to commit to a premium, specialised coaching 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.
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Neuro-Somatic Energy Coaching Intake & Screening Form
Welcome
Please enable JavaScript in your browser to complete this form.
Instructions for Client:
Section 1: Professional Background & Identification
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 safety protocols)
Section 2: The Gateway: Which coaching pathway are you seeking to enter?
Neuro-Somatic Energy Coaching (Blueprint) - High-level regulation, nervous system rewiring, and energetic field alignment for peak performance.)
Neuro-Somatic Hormonal Energy Coaching (Rebirth) - A sophisticated blend of endocrine health, neuro-somatic tools, and energy psychology for metabolic and hormonal peace.)
Section 3: The Deep Dive
Readiness Scale:
Number Slider
Selected Value: 0
Section 4: Your Somatic Story & Support Ecosystem
The Somatic Narrative: Traditional coaching often operates purely in the mind. My practice utilises active neuro-somatic rewiring and energy psychology. Please briefly describe how your history is currently impacting your physical body, nervous system, or energy levels (e.g., chronic exhaustion, hypervigilance, physical tension, hormonal flares).
Current Support Team: Are you currently working with any other practitioners (e.g., GP, Endocrinologist, Nutritionist, or Therapist)? This helps me ensure our work is complementary to your existing care.
Healing & Development History: Have you previously engaged in coaching, therapy, or energy healing? If yes, what was your experience with those modalities?
Section 5: Hormonal & Metabolic Focus
Bio-Markers: Are there specific hormonal or metabolic concerns you are currently navigating? (e.g., Thyroid issues, PCOS, Perimenopause, Adrenal Fatigue, Chronic Fatigue Syndrome, or Cycle Irregularities).
requires foundation this
Section 6: Safety & Stability Check
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 contact your local emergency services or crisis support line, as this coaching container is not a substitute for crisis intervention.)
Section 7: Alignment, Investment & Legal Consent
Pathway Investment Confirmation:
Professional Coaching Assessment (90-minutes): £550 (This mandatory assessment maps your nervous system and determines your bespoke coaching roadmap.)
Practice Boundaries & Consent: (Please check all to confirm)
Container Commitment: I understand that this practice is dedicated to deep, multidimensional energy coaching 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.
Medical Non-Advice Disclaimer: I understand that Neuro-Somatic Energy Coaching is not a substitute for professional medical advice, diagnosis, or treatment. I acknowledge that this is a coaching relationship and not a medical or clinical endocrine service.
Environmental Consent: I commit to being in a private, quiet, and safe space for my 90-minute assessment, where I can move or sit comfortably and speak freely without interruption.
Investment Readiness: I am ready to commit to a premium, specialised coaching 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.
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