welcome

It may take up to 20 minutes to complete this form
Answer only what feels most relevant to what your needs are.

Please have this completed before the day of our scheduled appointment. * Any information you share will be treated as confidential.

Welcome to the greatest QuEST of your life! Everyone has a story. “The work” you’re embarking upon is a journey which allows you to consciously recreate your story by design moving forward in life.

Our journey begins with us connecting and becoming acquainted, so let’s get started.

You are the star of our collaboration, and it's important for me to understand as much as possible about you and what's on your mind before we meet to map out our work together.

This questionnaire will prepare us for a productive dialogue by helping me learn more about you, your motivations and aspirations for our sessions. As well as any patterns or obstacles that may show up to sabotage your progress.

Intake Form for Shawna Pelton | Coaching & Therapy

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Full Name *

First

Last

Birth: Date, Time & Location *

Phone Number (can I leave you texts? Y or N) *

Best Email *

Address *

What are your reasons for wanting to receive healing or coaching? (challenges or aspirations) *

Write out your goals with specificity *

Are you in a partnership? Do you have children? (living or deceased) *

Have you had a history of any mental/physical/emotional health issues I should be made aware of? *

Name and # of an emergency contact *

What steps, if any, have you taken to work on this challenge up until now *

Has anything kept you from pursuing this in the past? *

Did you grow up with or currently have religious beliefs or spiritual traditions that are important to you? *

Do you have any concerns regarding your physical, mental emotional, or relational safety? *

Is there anything I didn't ask that you'd like for me to know? *

Transformational Healing & Coaching is about achieving results while making a positive permanent SHIFT.
I’m honored that you’ve chosen me to facilitate you towards your goals for a more fulfilling life, whatever that may look like for you; improving your mindset, health or relationships, or business.

No powerful story is free of challenges. I trust yours includes battles and victories.

It’s now time for a change in your life, to break through the unnecessary patterns of struggle and overcome the obstacles that entangle you to a painful past so you can Self-Actualize, living authentically, with meaning and purpose.

I am here to assist you in the process so that you can heal, thrive, up-level your life and ultimately experience joy in the way it is meant for you. I am honored to be on this journey with you and anticipate a glorious experience in the continuation of your unique and EPIC life Story.

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What to expect after a healing or coaching session + any contraindications to the work

It's possible to feel anywhere from incredibly light to very tired up following a session.

Healing work has the potential to unearth deeply seeded wounds. As a result, one may feel temporarily destabilized by the experience. This is normal, and the degree of which it affects ones life is dependent on many factors....including what's going on in your world, how supported you are, and how much self-help work has been done prior. As uncomfortable as it is to feel "off", so long as you allow the energy to flow and not supress it, it'll pass through.

Things that help the energy pass through are taking a bath or soaking feet in epsom salt, magnesium supplements (except in the case of bipolar disorder), drinking extra water, journaling your thoughts, getting outside in nature, bear feet in soil, creating something (art is an expression that helps move energy) or talking to your therapist. (you can contact me if there's ever a concern)

Avoid high stress situations following a session.

I do not work with people who suffer from schizophrenia or personality disorders, or for those who aren't able or willing to grant permission, or those who do not accept responsiblity for their part in their patterns.

Pregnancy and cancer are contraindications for the deeper work I provide, but I also have gentle healing sessions that are beneficial.

I don't recommend the deep work with those in living environments that are an active threat to your wellbeing, but my coaching and gentle energy work can help support you through difficult times until you're ready for more.

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IN CASE OF UNEXPECTED EVENTS

If you need to reschedule an appointment, please try and do so at least 24 (ideally 48) hours before our scheduled session

I understand that life is unpredictable sometimes, if you have can't make the appointment due to an emergency, health or professional reasons, I undestand and we can reschedule no problem.

If you no show for an appointment due to non-essential reasons, you will be responsible for the cost of the full session.

I will honor these same rules for myself; if I miss a session for a non-essential reason without proper notice I will provide you an extra session on me. If I'm sick or have an emergency, I assume you'll be understanding.

If you pay in full for a series, but have a valid reason to stop the work, I will refund any unused funds (I do not refund for time spent)

If there's an emergency situation that leaves me unable to uphold my end of the bargain, I can either refer you to a practitioner (when possible) who can complete the work with you, or refund you if you've prepaid for sessions.

Save this link for future reference

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Please review this agreement form before we begin our journey together.

Our agreement

I (when you submit, you agree this represents you) understand that working with Shawna is not a replacement for medical care. I assume full responsibility for my life and am ready to receive path-work guidance as a willing and able body participant and accept the benefits that are destined to come from my efforts. I will be honest and open along the way so to communicate my needs and adjust this agreement as needed.

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Shawna Pelton, from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

My commitment to you

I, Shawna J Pelton, am committed to doing my part as a fully insured, experienced, and certified facilitator to assist you per our client/guide verbal agreement we came to in your initial discovery call. I utilize a variety of tools and services that will support you in attaining your goals, but do not make claims for expected outcomes, diagnose or treat disease.

I will stay honest & present while maintaining a safe nurturing space to help you reach your highest outcome…whatever that may be.

If during our time together you’re holding back in a way that prevents you from having success in reaching your goals, I’ll do my best to help you overcome resistance, but essentially, you're the captain of the ship.

This contract is negotiable as we evolve through (y)our journey. I honor the integrity of this agreement and appreciate your participation in co-creating it.

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Intake Form for Shawna Pelton | Coaching & Therapy

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