Fill in the form before your session

in-take form

SIT Client Intake Form

Full Name *

Preferred Name

Email *

Occupation *

Emergency Contact Name *

Emergency Contact Number *

Please list any medical conditions your practitioner should be aware of

Please list any words, subjects, emotional triggers or boundaries your practitioner should be aware of

____________________________

Please rate the following statements with 0 being "I really struggle with this" and 10 being "Yes, that's 100% me!"

I have lots of energy and stamina *

I experience deep and restful sleeps consistently *

My digestion has regular bowel movements and no pain/bloating *

I am proud of my eating habits *

I intentionally move my body with exercise more than 3x a week *

I am happy with my sex drive *

I am happy with my intimate relationships *

(Women Only) I have a healthy relationship with my menstrual cycle

(Women Only) My menstrual cycle does not cause me pain

I have my own hobbies that bring me joy *

I have a daily meditation/prayer/gratitude practice *

The thoughts I have towards my body are positive *

I enjoy spending time in silence with myself *

I am a trusting person *

I have a strong community around me *

I feel supported and encouraged by my romantic partner (if applicable) *

I feel supported and encouraged by my parents (if applicable) *

I feel valued in my relationships *

There are people who do not deserve my forgiveness *

I often worry about what people think of me *

I feel confident expressing my needs/desires/wants *

I feel proud of myself and my life *

I spend too much time watching TV and/or surfing social media *

I often feel lethargic and out of touch with life *

I often feel like I don't belong and "want to go home" *

I am excited about my future *

How often do you move your body/exercise/play? What sort of activities do you engage in?

Do you have a daily commitment, practice, or ritual? If so, please explain

What areas of your life are you most content & happy with? Please explain

Please list the physical symptoms (pain/illness/disorder, etc) you're looking to resolve

Please rate the physical pain

With 0 being "It's minor" and 10 being "It's unbearable"

Please list any emotional symptoms you're looking to resolve

Do any of these symptoms worsen with certain activities, environments, people, or circumstances? Please explain

Have you sought other professional assistance? Please list what has worked and what has not. Please list your experience seeking other practitioners.

Are you aware of any prenatal OR birth trauma you OR your mother/father endured during the time your mother was pregnant or in labor? Please explain

At the end of 4 sessions working together, what would need to happen and how would you need to feel for you to know the time working together was 100% worth it? Please explain in detail

Session Expectations

Please know, the practitioner is not intended to act like a licensed therapists or counsellor.

You have control of the session and will never be pushed to release information you're uncomfortable with talking about. *

I understand and Agree

After a SIT session, it is perfectly normal to experience: A continued release of emotions.

Simply allow yourself to experience and observe the emotions that come up without judgement and especially without trying to change them. It's completely normal to feel angry, irritated, or "off" after this work. Don't worry! This is all part of the process. Remember: Emotions are your body and mind's way of communicating with you. Get curious about what's being communicated. With the subconscious mind, not only are certain emotions experienced, but we are also accessing different parts of your brain that have been "sleeping". This can be extremely exhausting. Honour that. *

I understand The Possible Effects.

After a SIT session, it is perfectly normal to experience: Thirst.

Please make sure to drink lots of high-quality water after your SIT session to help release any toxins that your body is working hard to remove. *

I Understand The Possible Effects

After a SIT session, it is perfectly normal to experience: Hunger.

You may experience intense hunger or strange cravings. This is completely normal. Your body worked hard to release the memories and emotions that were addressed in your session. Make sure to give it the fuel it requires. *

I Understand The Possible After Effects

After a SIT session, it is perfectly normal to experience: Pattern realizations.

Often times, when certain patterns are uncovered in your life, you will continue to experience revelations about your past, relationships, belief systems, etc., that are keys to your transformation. Make note of these insights and enjoy the new gift of deeper self awareness. *

I Understand The Possible After Effects

Client Agreement

We appreciate the opportunity to discuss your current symptoms and concerns. We wish to make it clear that it is not our intention to diagnose, prescribe, or cure, but to offer recommendations and information to help you on your journey of transformation. If you require medical assistance, please consult a medical practitioner. Please do not make any adjustments to the prescribed medication without the approval of your doctor. If in doubt, please seek your GP's advice. In this session, the practitioner may discover the "root cause" of your current symptoms through conversation and muscle testing. The root cause is often a hidden belief or decision you made due to a specific life event, experience, trauma, or influence. The practitioner may ask deeper questions to gain a better understanding of the event so they can effectively remove the impact it's had on your subconscious mind and in your current life. *

I Understand and Agree

Signature

By signing below with your initials, you agree that the practitioner is not responsible or liable for any adverse side effects, nor are they guaranteeing immediate results. You're also stating that you have had the opportunity to ask questions, and agree to receive the modality of Subconscious Imprinting Technique. Finally, you acknowledge that the practitioner who is representing SITwithit.co is assumed to operate in an ethical manner, however, their actions are not a reflection of SITwithit.co *

Clear

Date *