Cyclic Wisdom Intake Form (Individual Sessions)

This document is to inform you about what you can expect from me and from our work together and to give you the opportunity to give consent to proceed with this process. I’m happy to discuss any questions you may have before or during the time we work together.

First and Last Name

First Name

Last Name

Birth date

YYYY

Email address

1. How did you hear about my services?

2. How familiar are you with counseling? How has your experience been?

3. What is the reason for seeking counseling and what would you like to achieve?

4. What drew you to Cyclic Wisdom counseling?

5. Please introduce yourself in a couple of sentences.

6. Healing, gaining insight & compassionate understanding requires 100% commitment to your therapeutic process. Please share what you need from me to support your full commitment.

7. What other resources do you have that can support your journey? (close friend(s), family, practices, hobbies, interests, etc)

8. What does your menstrual cycle mean to you & how is your experience of it (feelings, energy levels, symptoms)?

9. At what age did you have your menarche? What did it mean for you?

10. Do you change your life(style) in any way when you bleed?

11. What does being a woman mean to you?

12. How is your relationship with other women, including those in your family like (grand)mother, daughters, nieces, aunts, & friends, strangers, icons, role-models?

13. Is there anything else you would like to add?

Thank you for the time and care that you put into answering these questions, for willing to look into your needs, and for making the time & commitment to your inner process.