Inner Alchemy — New Client Screening

First Name

Last Name

Email Address

What city are you located in?

Are you 18 or older?

Must be 18+ to participate, This practice does not work with clients under 18.

Are you 18 or older?

Yes, I am 18 or older

No — I am under 18

Date of Birth

How did you hear about Sarah?

What brings you here?

What services are you interested in?

Hypnotherapy Sessions

Individual Coaching

Dreamwork Sessions

Group Programs and Workshops

Personalized Guided Imagery and Meditations

Not sure yet — open to guidance

Mental Health & Safety

For the safety and wellbeing of all clients, hypnotherapy and coaching are not appropriate for individuals currently experiencing active psychosis, dissociative disorders, epilepsy or seizure conditions, severe or untreated depression, or active mania. If any of the above applies to you, this program is not the right fit at this time, and I can help point you toward the right support. For active PTSD, a referral or coordination with your treating provider is required before we begin.

The following questions help me make sure we're working together in the safest and most effective way. Certain conditions require specialized support, answering yes to some of these doesn't mean we cannot work together, but it does mean can a conversation about it prior to working together.

Are you currently, or have you ever been, diagnosed with any of the following?

Select all that apply.

Are you currently, or have you ever been, diagnosed with any of the following?

Schizophrenia or psychotic disorder

Dissociative Identity Disorder (DID) or dissociative disorder

Bipolar disorder

Epilepsy or seizure disorder

Active PTSD (currently destabilizing)

None of the above

Are you currently working with a therapist, psychiatrist, or other mental health provider?

Yes

I have in the past

Are you currently experiencing thoughts of harming yourself or others?

I have had these thoughts in the past, but not currently

Yes — I would like support with this

If you are in crisis:

If you are experiencing active suicidal thoughts or a mental health emergency, please contact the 988 Suicide & Crisis Lifeline (call or text 988), or go to your nearest emergency room. This is a coaching and hypnotherapy practice — it is not a therapy service and is not a crisis intervention service. Clients who are actively suicidal or a risk of harm to themselves or others are not appropriate for this program.

Are you currently in an acute mental health crisis, or experiencing a major destabilizing life event?

e.g. recent hospitalization, active psychosis, severe acute trauma

Are you currently in an acute mental health crisis, or experiencing a major destabilizing life event?

Yes

Somewhat — I'd like to discuss

Please list any current medications or write "none"

Hypnotherapy Readiness

Have you experienced hypnosis or hypnotherapy before?

Yes

If yes, what was your experience like?

Do you have any concerns or ideas about hypnosis you'd like addressed?

On a scale of 1–10, how motivated are you to make change right now?

1 = curious but not urgent · 10 = ready and committed

Your Goals and Vision

If we work together and it goes really well, what do you imagine your life would look like a year from now?

Dream a little. What are you feeling? What's different?

Is there anything else you would like me to know before we speak?

Investment range

This is not a commitment — just helps me understand how to best support you

Investment range

$500–$700 / month — ongoing flexible support

$1,200–$1,500 / month — committed container over 3–6 months

$2,000+ / month — deep, long-term transformation

I'm honestly not sure yet — open to discussing options

Investment is a real constraint for me right now

Confidentiality & Consent

The information you provide in this form is strictly confidential. It will be held securely and will not be shared with any third party without your written consent, except as required by law. Sarah Manuwal's coaching and hypnotherapy practice operates as a separate entity from her AMFT clinical practice.

This form is for screening purposes only and does not constitute a therapeutic relationship. Completion of this form does not guarantee acceptance as a client — Sarah will review your responses and reach out within 2–3 business days to confirm next steps or, if needed, discuss fit or referral options.

By submitting this form, you confirm that the information provided is accurate to the best of your knowledge.

Signature

sarahmanuwalhealing@gmail.com · Los Angeles, CA · 2026