• SOMASHADOW METHOD™ •

Intake Form

When the Body Keeps Score — Understanding the Emotional Roots of Thyroid, Autoimmune & Metabolic Conditions

A note before you begin

This form is not a questionnaire. It is an invitation — to bring genuine attention to your experience before we meet.

There are no right answers. There is no box to tick correctly. What I'm asking for is honesty, with yourself more than with me. The more truthfully you engage with these questions, the more you'll receive in the session.

Your responses are held in strict confidence. They will never be shared. I read every intake form personally, the morning of the session.

PREPARATION

20-30 Mins

Sit somewhere quiet.
You deserve that.

Your name and how you prefer to be addressed * First name and preferred name (how you would like me to address you in session)

Where are you joining from? * City / country — helps with timing and cultural context

How long have you been living with your primary condition? *

Less than 1 year

1–2 years

3–5 years

6–10 years

More than 10 years

Are you currently on medication for your condition? *

Yes — prescribed and taking regularly

Yes — prescribed but inconsistently

Recently stopped / in process of tapering

No medication

Under investigation — diagnosis not yet confirmed

Other:

Are you currently working with any other practitioners? * Select all that apply

Endocrinologist / Specialist

General Physician / GP

Functional Medicine Doctor

Naturopath / Homeopath / Ayurveda

Nutritionist / Dietitian

Therapist / Psychologist / Counsellor

Yoga / Movement therapist

None currently

Other (specify below):

Your Experience of the Condition

Not the clinical picture — the lived one

In your own words - how does your condition affect your daily life? * Not the medical description. The actual lived experience. What does a difficult day look like?

What have you tried so far? * List anything - diet changes, supplements, protocols, alternative approaches, therapies.

What has helped - even partially? What has not helped at all? *

How would you describe your current relationship with your body? * Choose the description that resonates most, or write your own.

We are at war — I feel like it is working against me

Estranged — it feels like a stranger I no longer recognise

Cautious — I work around it rather than with it

Complicated — there are moments of connection and momments of frustration

Curious — I am beginning to listen differently

Other:

The Gap

Many people with chronic conditions experience a gap - between what their reports say and what their body actually feels.

How significant is this gap in your experience? * 1 = no gap (reports match how I feel) | 5 = enormous gap (reports are 'fine', I am not)

Not at all

Completely

In your own words - what does this gap look like for you? *

The Emotional Landscape

The questions nobody usually asks · 10 minutes

Why these questions

The SomaShadow Method works at the intersection of emotion and physiology. These questions are not personal prying. They are the map of the territory we work in. Answer as honestly as you can. There is no wrong answer. Resistance to a question is also information.

Think about the year your condition first appeared - or significantly worsened. What else was happening in your life then? * Relationships, work, family, loss, major transitions — anything that comes to mind.

Are you the person others come to?

The one who holds things together, solves problems, shows up reliably for everyone around you.

To what degree does this describe you? * 1 = not at all | 5 = this is my defining role

Not at all

Completely

What is the cost of this role - on you? *

How comfortable are you with saying no? * Specifically, to people you love, or people you depend on, or people who depend on you.

Very comfortable — I say no easily when I need to

Somewhat comfortable — I can do it but it costs me something

Uncomfortable — I rarely say no and feel guilty when I do

Very uncomfortable — I almost never say no, regardless of what I need

It depends entirely on who is asking

What happens in your body when you are about to say no to someone important? *

When you feel angry, overwhelmed, or deeply upset - what do you do with it? * Not what you think you should do. What you actually do.

I express it directly — to the person or situation

I talk it through with someone I trust

I go quiet and process it internally

I bury it and get on with things

I redirect it into work or productivity

I turn it on myself — guilt, self-criticism

I don't always know I'm feeling it until it's already in my body

Other:

How long do you typically carry an emotion before it has an outlet? *

QC5 Is there something you have needed to say — to someone, or to yourself that you haven't said? * You don't need to name it explicitly here if you'd rather not. But notice if something arises.

Yes, and I know what it is

Yes, but it's not fully clear yet

I'm not sure

If you are willing to share anything about it - even loosely: *

Your relationship with rest, pleasure, and wanting

These three are often deeply connected to metabolic and hormonal conditions.

How easily do you rest — without feeling guilty or unproductive? *

What brings you genuine pleasure right now? * Not what should but what actually does.

Is there something you have wanted for yourself, that has felt selfish, unrealistic, or simply not allowed? *

The performance of wellness

Many high-functioning people with chronic conditions have become skilled at appearing fine - even when they are not.

How often do you perform being okay - when you are not? * 1 = rarely | 5 = almost always

Rarely

Almost always

Who in your life actually knows how difficult this has been? *

What does it cost you to keep performing fine? *

Grief (Optional) Skip it if it doesn't feel relevant. Sit with it if something moves.
Living with a chronic condition often carries grief - for the life that was, for things not done, for the version of yourself before the diagnosis.

Is there a loss, however quiet, connected to your condition that you have not fully mourned?

Yes

I don't know

Other:

Your Relationship to This Work

Where you are starting from

How did you hear about Somashadow? *

Instagram/ Facebook

A friend or colleague

A practitioner recommended it

Google / online search

Email newsletter

Other:

What made you register? * Not the polished answer - the honest one. What was the internal reason?

How familiar are you with the mind-body connection? *

Completely new - I've never explored this

I've heard of it but don't know much

I understand it intellectually but haven't worked with it personally

I've read about it (Gabor Maté, etc.) but haven't found a practical application

I've done some mind-body work — with mixed results

I already work in this space to some degree

If you've read anything about the mind-body connection that has stayed with you — what was it? *

How familiar are you with shadow work? *

Never heard of it

Heard the term but unsure what it means

Have a basic understanding

Have explored it personally

Already practice it in some form

How familiar are you with Bach Flower Remedies? *

Never heard of it

Heard of them but know nothing about them

Have some knowledge — haven't used them

Have used them in the past

Currently using them

What is your level of scepticism going into this session?

Scepticism is welcome here. It makes for the most interesting conversations.

How sceptical are you? * 1 = open and ready to receive | 5 = very sceptical but something brought me here anyway

Open and ready to receive

Very sceptical but something brought me here anyway

Safety & Context

Important — please read carefully

◆ About this section

The SomaShadow Method works with emotional material that can sometimes surface unexpectedly.

These questions help me understand your context — so I can hold the session appropriately for where you are.

There are no disqualifying answers. Honesty here keeps you safe.

Are you currently experiencing significant mental health challenges? * Acute depression, anxiety disorder, PTSD, grief from a recent loss, or anything that is making daily functioning difficult.

No — I am reasonably stable

I have some background mental health challenges but they are managed

Yes — I am going through a difficult period right now

I'd rather not say

Anything you'd like me to know: * If yes — this doesn't prevent you from attending. It means I will hold the space with additional care, and may reach out to check in with you before the session.

Are you currently working with a therapist or mental health professional? * Note: If you are working with a therapist, you are welcome to share what comes up in this session with them. The two processes support each other well.

Yes — actively and regularly

Yes — occasionally

Not currently, but have in the past

Is there anything in your current life circumstances that I should be aware of as I hold this session? * A recent bereavement, a relationship breakdown, a major transition, a medical procedure — anything that contextualises where you are right now.

Do you have any concerns about participating in this session? * Any hesitations, worries, or things you'd like to raise before we begin.

◈ Scope of Practice — please read

The SomaShadow Method masterclass is an educational and experiential event. It is not therapy, counselling, or medical treatment. Nothing shared in this session should be used to replace medical advice, diagnosis, or treatment from a licensed professional.

Participation in this session does not create a therapeutic or clinical relationship between you and [Your Name].

If you are in acute mental health distress, please speak with a mental health professional before attending.

Your Final Word

The question that matters most

If your body could speak directly to you right now — what do you think it would say? * Not what it should say. Not what would be elegant or insightful. What it would actually say.
You don't need to make sense of this. You don't need to be poetic. Write whatever comes - even if it is just a feeling, or a word, or 'I don't know.'

Is there anything else you'd like me to know before we meet? * Anything at all — that doesn't fit in the questions above.

Thank you.

What you have just written took courage. Most people never ask themselves these questions. The fact that you did — already tells me something important about where you are.

I will read this before we meet.