Conscious Emotional Mapping · 75 minutes

Intake form

Please complete this before your session. There are no right answers and you do not have to fill every box. What you write here shapes the whole session, so short and honest beats long and polished.

1 · Your details

Name

Session date

Phone or email

Online or in person

2 · Sleep and energy

Over the past two weeks.

Roughly when do you fall asleep?

And when do you wake?

Nights a week you wake and struggle to get back to sleep

If you do wake, what time is it usually?

Your usual energy. 0 = nothing left · 5 = fully there

Morning

Early afternoon

Evening

3 · The pattern

What made you book this session?Which reaction comes back most often for you? Your own words, not a label.What sets it off — situations, people, times of day?Once it arrives, how long does it stay?

When do you first remember noticing it?

4 · Your body

When you are under strain, where in your body do you notice it?Anything tight, sore or numb for more than three months?

Persistent physical pain should be seen by a doctor. This question does not replace that.

How true is each for you? 0 = never · 5 = always

I notice something in my body before I notice the feeling

When I am upset, I can tell where in my body I feel it

I ignore physical discomfort and carry on

I trust what my body is telling me

5 · How the last two weeks have been

0 = at no time · 5 = all of the time

I have felt steady in myself

I have woken up feeling rested

I have felt interested in things

I have enjoyed ordinary parts of the day

I have felt able to handle what came up

In your own words — if this shifted, what would be different?

6 · Safety and preferences

We do not need names, diagnoses or details. These exist so nothing suggested in your session conflicts with something else, and so the breathing practice chosen for you is safe.

Are you currently under the care of a doctor, therapist or psychiatrist?

Are you taking any prescribed medication?

Are you pregnant, or trying to conceive?

Heart condition, high blood pressure, epilepsy, or history of panic attacks?

Would you prefer your remedy prepared without alcohol?

Please read before submitting. Conscious Emotional Mapping is a wellness reading. It is not a medical or psychiatric diagnosis, it does not treat illness of any kind, and it does not replace care you are already receiving. If something comes up that needs clinical attention, we will say so plainly and point you towards it. If you are in distress at any point, Tele-MANAS is free and open 24 hours a day on 14416.

I have read the above and would like to go ahead.

Nothing is stored on a server. Your answers travel with the link you send.