Application for Intro Couple's Session
Hello! 

Thank you for your interest in working with me. Please each answer the following questions, in separate forms, to help me to determine if it makes sense to move forward with an intro session. If there is a question you are uncomfortable answering, please feel free to mark n/a. While it is possible you may receive a reply from my assistant, please rest assured that your answers will kept confidential and will only be read by me. Replies can take up to a few weeks, but usually sooner. All inquires will receive a response. 

In addition to couples coaching I am a trained and certified trauma resolution guide, specializing in complex-PTSD. I practice somatic trauma-resolution modalities and Brainspotting, as well as archetypal and mindfulness based modalities. Our romantic relationships are often where we become most activated, and where we tend to project our childhood traumas and attachment wounds. I bring my skills and expertise in this area to my couples coaching as needed. I am also a meditation teacher, a grief recovery coach, and offer support with chronic pain and illness. 

I'm looking forward to connecting with you!

With warmth and gratitude - 

Jess
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Email *
Name *
Pronouns
Your Partner's name  *
Age  *
Time zone *
I see clients Monday - Thursday. My first session starts at 11am PT, my last session starts at 5pm. On occasion I have a Friday slot available. Please list the days and times that are best for you and your partner in the next few weeks (only one of you needs to fill this portion out).
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How did you find out about my couples work? *
What aspects of your relationship are feeling really good? *
What aspects of your relationship are feeling most challenging? *
Have you recently experienced any big loss or life transition? *
Do you have any chronic illnesses or experience chronic pain? Do you experience migraines or seizures? *
Keeping in mind that my priority will always be safety and consent in this work, are you in a place in your life where you have the capacity to delve into the sometimes challenging material that can arise in this type of work (ie. experiencing strong emotions, changes to relationship dynamics, processing past experiences, psycho-spiritual side effects, integrating new ways of operating, etc.)? *
Have you been diagnosed with any mental illness or personality disorder? If so, are you currently being treated for this? This will absolutely not disqualify you, but as I am not a therapist it's important that I know you have additional support if needed. I also need to be sure that working with you is within my scope of practice.  *
Understanding that we will not delve into anything highly triggering and we will move at a slow and safe pace in this intro session, do you agree with the following: I acknowledge and understand this intro session is no way a substitute for medical diagnosis and/or treatment of any kind. I acknowledge and understand that I am responsible for all aspects of my health and wellbeing, and that meditation and working with trauma may involve physical, mental, intellectual, and emotional activity that may be strenuous and destabilizing. I acknowledge that it is my sole responsibility to exercise my own judgement in choosing to participate in this intro session.  *
Are you currently or have you previously worked with a couples coach, guide, or therapist? If so, what worked great for you and what didn't? *
The intro session is meant to be supportive and beneficial regardless of if we move forward with more sessions. Please plan for between 30 and 90 minutes. This is not a sales call. 

The cost of my couples support is dependent on what the focus of our work is. Depending on how we work together, Rates range between $300 - $6500, with varying level of support. I prefer 6 month commitments with new clients, but we can discuss what will best suit your needs. 

I will send you specifics on rates and containers BEFORE our intro session. There will be no pressure to sign up for further sessions after the initial intro. We will both take a few days after our session to consider if it's a match. I do not take anyone on as a client until we have both had a chance to digest our time together. If I feel that I'm not the right person for you, I'll be happy to offer you some referrals. 

If you or your partner is a member of an underrecognized, and/or historically and intentionally excluded and disinvested community and my rates are cost-prohibitive for you, please feel free to ask me about a discounted rate. 

At this time I am only able to offer intro sessions to those who are seriously interested in couples support at this time. If we decide to work together, is making a financial investment doable for you at this time? 
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What would feel like a miracle for your relationship in the next 3 - 6 months? *
What or who makes you feel happy and safe? *
What are three things you love about your partner?
Are you willing to dedicate time each week, outside of sessions, to do homework together? This can include intimacy practices, writing exercises, structured conversation, and more. 
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Are you ready to change patterns in your relationship, even if that means periods of growing pains and stepping into unknown territory together? 
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Is there anything else you’d like me to know about you before we meet? Share as much or as little as you like. *
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