Request appointment | Freedom Wings PLLC

What experiences or feelings have guided you to seek support and healing at this time?

(choose any/all that resonate.)

Past trauma or unresolved experiences Grief or major life transition Relationship strain or boundary issues Seeking balance, clarity, or renewed purpose Physical symptoms related to stress or emotional pain Stress, overwhelm, or burnout Anxiety, panic, or racing thoughts Desire for personal growth or deeper healing Depression, loss of motivation, or sadness Feeling disconnected or emotionally numb Other

Which modality or speciality are you seeking?

Select as many as interests you.

Psychotherapy (Talk therapy or processing emotions) EMDR or trauma-focused work Hypnotherapy or guided visualization Ketamine-Assisted Psychotherapy Body Balance Therapy (Somatic or body-based awareness work) Unsure

Do any of these apply to you?

select all that apply

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons recently Hospitalized for mental health reasons in the past Attempted suicide in the past None of these apply

Have you worked with a therapist or other healing professional before?

Yes No

What are your goals, hopes, or intentions for your healing journey?

(Check or circle all that apply, or add your own in the space below.)

Heal from past trauma or painful experiences Explore inner child or parts work Improve emotional regulation and self-compassion Strengthen relationships or set healthier boundaries Feel more grounded and balanced in daily life Integrate mind–body–spirit healing Prepare for / integrate psychedelic or Ketamine-assisted therapy

Are you open to exploring holistic or mind–body approaches as part of your care?

How ready do you feel to make meaningful changes that support your healing and growth?

Rate your readiness

5️⃣ Very ready (like yesterday) 4️⃣ Almost ready (maybe today, maybe tomorrow) 3️⃣ I’m just exploring my options 2️⃣ Kinda (I know something needs to change, I’m just not there yet) 1️⃣ Not ready at all (but I’m here, and that counts)

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