Intake form

Help us serve you better

Name *

Email address *

Age

Gender

Which of the following conditions or traits do you identify with?

Please select at least one option.

Rejection Sensitive Dysphoria (RSD)

Anxious attachment

Disorganised attachment

ADHD

Autism (AuDHD)

Emotional dysregulation

BPD traits

Childhood trauma

Have you previously received any form of therapy or coaching for these conditions?

What are your primary goals or areas of focus for coaching or support?

Do you have any current medications or treatments related to your conditions?

If yes, please list your current medications or treatments.

How did you hear about the wound beneath the want?

Which service or services are you interested in?

Please select at least one option.

Additional questions or comments

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The wound beneath the want