Intake Form – Work with me

Deliber8 with Dana

You don’t have to have it all figured out. Just start here.

Deliber8 with Dana is 1:1 mentoring designed to meet you where you are.

Together we can untangle what’s been confusing, rebuild trust in yourself, and create safety where it’s been missing.

It’s about creating space for self-honouring expression, realignment, and grounded next steps.

You don’t have to figure your ‘how to human’ journey out alone – I’ve got you!

Intake Form to Work With Me

NOTE: Those that are toggled [required] help direct me to what brought you here and how I can best assist you.

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Your intake has been sent

Basic Information

Full Name

Preferred Name (if different) OR Phonetic Pronunciation

Phone

Best time to reach you (required)

Afternoon (noon – 4 PM MST) Evening (5 PM MST onwards)

Location (city) and Time Zone

Let’s align you with the most appropriate sessions

REMINDER: Although the following aren’t toggled [required], these answers help direct me to what brought you here and how we can make the most out of our sessions(s).

Who are these sessions for?

You Family Member Teen Child

Age Range

Which of these feels like you right now? (if any)

“I’m tired of feeling like my family story defines me.” “I feel lost in labels that don’t actually fit me.” “I keep second-guessing myself.” “I know I need to make changes, but I don’t want to burn my whole life down just to feel better.” “I’ve been told I’m too sensitive, too loud, too intense… I just want to feel like I’m not a burden.” “My brain feels like a knot of wires – where do I even start?.”

Past Support

Therapy / Counselling Coaching / Mentorship Self-directed None

Feelings you relate to (if any)

You believe you're not good enough, or that your feelings don't really matter You worry that talking about something hard will make it hurt all over again You have anger that's been hiding for a long time that suddenly shows up and feels too big too handle You open up honestly, but people react like you've said too much What you believe in or who you think you are is starting to shift and nothing feels steady You miss feeling like you have a place or people who really see you Everything you've been holding in is starting to pour out all at once

Session Details

IMPORTANT: Those that are toggled [required] indicate your session duration and time requests, as well as your preparedness for this type of 1:1 mentorship.

Tech Setup – Do you have ZOOM & reliable internet?

How many sessions do you need RIGHT NOW?(required)

ONE – 30-minute session ONE – 55-minute session TWO – 55-minute sessions

Time Preference (please choose a minimum of 2 times) (required)

2:00 PM (MST) – 30- or 55-minutes 3:00 PM (MST) – 30- or 55-minutes 4:00 PM (MST) – 30- or 55-minutes 5:00 PM (MST) – 30- or 55-minutes 6:00 PM (MST) – 30- or 55-minutes

Session Day Preference (required)

Monday Tuesday Wednesday Thursday

What is on your mind

DISCLAIMER: Even though this section is not toggled [required], these answers address the reason you’re reaching out, and are necessary for background information.
Please feel safe and free to write what comes to mind, and what can help me understand your situation before we touch base. Please note that no information collected within this form will be used with any third party and only stored for correspondence to arrange sessions.

For Best Results, Please Include These Elements in Your Submission:

Main Topic / Subject / Rant Title A clear one-liner (if possible) that describes what this is about.

People, Feelings, and Elements Involved Who or what is involved? What emotional charges are surfacing?

Any Relevant Background (This could include relational history, cultural context, or past versions of the issue.)

Your Interpretation of Others’ Perspectives What do you believe they think or feel about this situation?

Patterns You’ve Noticed (If Any)

Is this a one-time event or does it repeat?
Are the same people, places, or triggers involved each time?
Has anything changed recently?

What You’ve Already Tried (If you’ve attempted to resolve or shift things – share what you did and what happened.)

How Long It’s Been Affecting You

Timeline of how long this has been present
In what areas of your life has it impacted you?

What You’re Hoping to Understand or Receive (Optional, but helpful. Are you looking for clarity, validation, reflection, suggestions?) – I typically call it:

Pause = witness/validation only
Perceive = perspective/insight, no pressure
Proceed = action steps + encouragement forward

The reason(s) / situation / event you’re reaching out

Any access needs or preferences you’d like me to know?

Anything else you’d like to share before we connect?

General inquiry from intake

By submitting this form and signing up for texts, you consent to receive contact correspondence regarding your inquired services with Deliber8 with Dana (or sister businesses: DSC Verse, The DANA Verse, and The DANA Model), and may receive minimal marketing text messages (e.g. promos) from Deliber8 with Dana (and/or limited material from sister companies) at the number provided. Consent is not a condition of purchase. Msg & data rates may apply. Besides initial contact for service coordination, Msg frequency varies. Unsubscribe at any time by replying STOP.

Intake Form – Work with me

Intake Form to Work With Me

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