Individual Intake Form for Deeper Love Sessions

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Confidentiality & Foundations

This form is private and confidential. What you share here will only be used to guide our sessions and support your journey. Your privacy and trust are of the utmost importance.

In this work, the focus is less on retelling stories and more on creating experiences of safety and newness in your nervous system. Together, we’ll pay attention to what arises in the present moment — the body’s signals, instincts, and emotions — as well as how you show up with one another in real time. This creates the conditions for repair, deeper intimacy, and sustainable change.

This work is deep and slow. When it comes to repatterning our attachment system, there’s no shortcut. Healing toward secure attachment asks that we keep showing up, even when the shifts feel small. Over time, those small moments accumulate into profound change.

My role is to offer a grounded, nonjudgmental, and compassionate space where you can safely explore, take risks, and meet one another in new ways. This process supports healing toward secure attachment and helps restore your original attachment blueprint — the innate capacity for love, trust, and connection that lives beneath old survival patterns.

STEP ONE.

Legal Agreement

By signing below, you acknowledge and agree that:

✓ I, Zoey Ann Stimpson, am a Somatic Experiencing Practitioner and Holistic Deep Wellness Mentor, specializing in body-based and unconventional approaches to healing and relationship repair.

✓ This work is not medical or psychotherapy, and is not a replacement for professional medical or psychological care.

✓ I do not diagnose or prescribe. You are encouraged to continue working with licensed professionals as needed.

✓ Outcomes cannot be guaranteed; you are responsible for your own healing journey and choices.

✓ I am not liable for outcomes, decisions, or consequences of our work together, including effects on your personal or relational dynamics.

Name

First Name

Last Name

I acknowledge that I have read and agree to the terms outlined above.

Yes

Date

Insert todays date of agreeing to this e-contract

YYYY

STEP TWO.

Individual Intake Form

Please answer these questions openly and honestly to help us understand your individual perspective and intentions for this work. Your responses are private, held with deep respect, and will help us create the most supportive space possible for you and your partner.

Personal Information

Preferred Name & Pronouns

How do you identify?

(e.g., male, female, non-binary, trans, etc.)

Cultural background

Religion or spiritual beliefs

Relationship status

(e.g., monogamous, polyamorous, open, etc.)

How long have you been in this relationship?

Do you currently live together? If not, please describe.

Do you have children? If yes, how many and what are their ages?

Health & Care

Is there anything about your physical or emotional well-being you’d like me to be aware of as we do this work together?

Are you currently working with any other professionals?

(therapists, doctors, coaches, mentors)

Are you familiar with Somatic Experiencing? If yes, please share any previous experience.

Is there anything you’d feel safer or more comfortable with me knowing?

Your Perspective on the Relationship

How would you describe the current state of your relationship?

What do you see as the greatest strengths in your relationship?

What do you see as the most significant challenges?

On a scale of 1–10, how well do you feel you communicate with your partner?

(10 = excellent)

How do you typically move through conflict or disagreement?

Do you see this as a conscious relationship? If yes, what does that mean to you?

What are you most afraid of in this relationship?

Have there been any particular fractures in the relationship? If you’re open, please share.

Intentions for Deeper Love

What is your personal intention for these sessions?

(e.g., deepen connection, repair, build more awareness, consciously transition, etc.)

On a scale of 1–10, how ready are you to shift old patterns — both personal and relational?

What is the one pattern you know could get in your way during this process?

(e.g., avoidance, shutting down, overextending, procrastination, boredom, lack of self-responsibility, excuses, high or unrealistic expectations, fear of intimacy…)

What do you find most satisfying about being in relationship?

What is your vision for your relationship moving forward?

Sexual & Emotional Connection

How would you describe your sexual relationship with your partner?

What do you find most satisfying, and what would you like to improve?

On a scale of 1–10, how open are you in sharing your innermost feelings, desires, and thoughts with your partner?

What topics feel most difficult to discuss, and why?

Attachment & Lineage

How is your relationship to your mother and father / early caregivers?

Are you aware of the science around ancestral trauma and emotional patterning?

Do you have any sense of how your lineage has impacted you?

(This is more exploratory — we will discover more together in the work itself.)

Commitment & Future Outlook

On a scale of 1–10, how committed are you to this relationship?

Where do you most want to experience transformation — intimacy, communication, trust, play, passion, safety, repair?

Are you willing to keep showing up for this deep, often slow (and powerful) work?

Are you open to reinventing love and what partnership can be?

Final Reflection

Is there anything else you’d like to share that would help me better support you?