Request edit access
Couples nervous system health work application
This will give me a better idea of if we are a fit to work together.
Sign in to Google to save your progress. Learn more
Your name and your partner's name & pronouns *
What's the context here? (Include details you feel comfortable sharing such as: you're in a monogamous partnership, you are polyamorous, in an open relationship, you're cis/ trans, hetero/ same sex relationship, how you each identify in your sexual orientation and or gender, etc.) *
What would you say is your couple's peaks (what is really working) and what are the pits (what is not currently working or where you struggle?)
What are you and your partner wanting to get nervous system health support for PRECISELY? (Example: helpful tips on effective communication with each other, navigating attachment styles and growing a secure attached partnership, identifying each other's love languages and how the other would like to be loved in discussion, etc.) *
Are you, or your love, or both of you, neuro-divergent (autistic, ADHD, SPD, I even count the HSP (highly sensitive person) as ND as you have way more mirror neurons than a NT)? If so, please give insight as you feel fit. *
Phone number to reach you at. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Emily Beatrix.

Does this form look suspicious? Report

Google Forms