AMPLIFYING CONSCIOUSNESS
WISE Intake Form
This intake is designed to help us see the full picture of your current landscape—what’s alive for you, where you’re feeling stretched or stuck, and what’s ready to evolve. The more openly and honestly you engage, the more potent our work together will be. There’s no right answer—only what’s true.
You’ll be engaging both reflective questions and evidence-based assessments to support a nuanced and accurate understanding of your current reality. This process is in depth and intentionally rigorous —a powerful first step in the work you’ll do here.
Please allow yourself unhurried time and space to move through it. What you offer becomes the foundation for a process rooted in clarity, care, and real transformation.
First let's get some personal information
Your preferred form of contact
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Any other details about your identity you would like us to know
Emergency Contact Details
Who were you referred by?
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This section helps us identify what's shaped your experience so we can best support you throughout the program.
Describe your educational/work background as it relates to your current
situation:
Are there any unusual or special circumstances that affected your development? (e.g. physical, sexual, or emotional abuse, mental illness, physical illness, learning
disabilities, neglect, alcoholism, separation from parents), other circumstances)
Let’s begin by orienting to your life right now.
What are 3–5 central commitments that are truly at the center of your daily reality? These might be roles, relationships, responsibilities, projects, or inner priorities. Give each one a little texture—enough that we can sense what’s moving you, what’s demanding your energy, and what matters most in this moment of your life.
Part 2: Domain Self Assessment
This section explores how you currently experience yourself across key domains of human development.
There are six areas: Cognitive, Emotional, Somatic, Relational, Spiritual, and Integrating. For each one, choose a self-assessment— Excellent, Strong, or Challenging —and then bring in examples for your choice.
Please don’t hold back here. Clarity is power, and this is a space without judgment. Everything you share is simply information—raw material that helps shape the most effective path forward.
Your thinking mind—how you process, plan, discern, make meaning, and navigate complexity.
I am able to notice what’s happening in a certain area (like business, philosophy, or cooking) and make sense of it.
From this understanding, I am able to see possibilities, make accurate predictions, and anticipate obstacles.
Your inner emotional landscape—your awareness of feelings, your fluency in naming and staying with them, and your capacity to move through them with maturity.
I am able to discern what I am feeling at this moment.
I am able to discern what emotions are present when I experience difficulties, etc.
I am able to discern the emotional state of others, even when they themselves may be oblivious to it or denying it.
I am able to stay in communication in the midst of strong emotional events, be they mine or others.
Your felt sense—how attuned you are to the messages of your body, and how you work with those signals. This is less about emotion, and more about embodied knowing.
I am able to notice what is happening in my body, e.g. energized, tired, heavy, open, tight...
I am able to include what I observe into my understanding of the current moment.
I am able to tap into the what my body is telling me, which may have a different insight into what’s happening than my intellect or emotion.
How you show up with others—your ability to connect, express clearly, listen deeply, and stay present in both harmony and conflict.
I am able to initiate and sustain mutually satisfying relationships.
I am able to listen deeply and communicate clearly with a wide variety of individuals and groups.
I am able to see the world from different points of view.
I am able to set aside my own desires for the sake of the relationship while maintaining a sense of my own worth and dignity.
Your connection to something larger—meaning, purpose, mystery. This could be through faith, service, nature, or your own evolving sense of belonging in the wider web of life.
I am able to create a life dedicated to the benefit of everyone.
I am able to engage in practices that strengthen my bond to the wide web of life.
I am an active member in a community dedicated to developing compassion, wisdom and service to others.
How you hold and balance the whole—how these areas weave together (or don’t), and how you meet the tensions and trade-offs of being a full-spectrum human.
I am able to bring my values and intuitions to all parts of my life.
I am able to resolve conflicts between work and personal life.
I am able to resolve conflicts between caring for relationships and caring for myself.
I am able to resolve conflicts between being true to myself and making a living.
I am able to resolve conflicts between all the other streams of development.
This is where we ask you to go deep.
What brings you here? What inner or outer challenge is calling for attention and transformation?
We invite you to be as clear and open as you can here. The more honest energy—mental, emotional, even physical—you can bring, the more powerful this work becomes.
Lasting change happens when the energy for transformation outweighs the energy keeping things the same.
Take your time. Reflect deeply. This is the heart of the form.
Here, we’re looking at your daily rhythms.
How do your habits, energy management, and lifestyle support or sabotage the work you want to do here? What practices nourish you—and what’s missing.
Have you completed the Vitality Pillars Assessment?
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How do rate your self in the following in the following areas:
Restorative and regenerative time
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Your self-care practices and any other details you'd like to share
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No one evolves alone. Who’s in your corner?
Whether it's a close friend, therapist, spiritual guide, or simply someone who sees you—name the people who help you feel held, witnessed, and supported as you grow.
Part 7: Future Possibilities?
Lean in here. Let this be visionary.
If the issue you named in Part 4 shifted—really shifted—who might you become?
What version of you is waiting on the other side of this threshold?
You don’t need a crystal-clear picture, but do feel into what becomes possible when you’re aligned, resourced, and true to yourself.
This is your space to name what didn’t fit neatly elsewhere.
What else feels alive, important, or wants a voice here?
Sometimes the process of reflection reveals unexpected clarity—if so, follow that. You’re welcome to expand, pivot, or refine what you shared earlier.
Thank you for taking the time to move through this intake with honesty and care.
We’ll hold what you’ve offered with respect and attentiveness as we begin this journey. You’re already in motion.
