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CLIENT INTAKE

SELF ASSESSMENT

This self-reflection is a private baseline - a snapshot of where your system is starting from, in 5 areas of your life.


Your responses will:

  • create a reference point for tracking change across the program

  • help you notice shifts in thoughts, emotions, and body responses

  • help to reflect on how far you’ve come


There are no right or wrong answers.

This is not an evaluation - it’s information.


Answer honestly, based on how things feel right now, not how you think they should feel.


You’ll complete a similar form at the end of the container.

Many clients find the comparison grounding, clarifying, and unexpectedly affirming. There are only 5 sections, and it takes about 5 minutes to complete.



ABOUT YOU
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DISCLAIMER:

 

All sessions are complementary wellbeing practices intended to support relaxation and nervous system regulation.

They are not a substitute for medical or psychological treatment.​​

© Rebecca Hine 2026

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ABN: 27138528678

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