7-Day Sleep Support — Intake Form

Welcome

Thank you for beginning your 7-Day Sleep Support.

This support is designed to work gently alongside your life over the coming week.

There is nothing you need to explain perfectly.

Simply share whatever feels most relevant right now, in your own words and at your own pace.

Your responses will help guide the support created for you.

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Name(Required)

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Email(Required)

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Phone

Location / Timezone

What feels most present for you at the moment?

What would you most like support around over the coming week?(Required)

You do not need to explain everything. Simply share what feels most emotionally or physically present right now.

How has your sleep been affected lately?

difficulty settling before sleep

waking frequently during the night

waking too early

vivid dreaming

shallow or restless sleep

stress-related sleep disruption

tension before sleep

emotional looping at night

waking feeling emotionally drained

difficulty calming the nervous system

inconsistent sleep rhythms

feeling exhausted but unable to fully rest

other

How emotionally or physically overwhelmed does this currently feel?

1 = manageable 10 = deeply overwhelming or exhausting

Are there particular times when things feel more difficult?

mornings

afternoons

evenings

late at night

during work

after emotional conversations

after social interaction

when alone

after overstimulation

no particular pattern

other

What would feeling more rested or emotionally supported look like for you this week?

Is there anything else you would like me to know?

Only share what feels comfortable and relevant.

I understand that 7-Day Sleep Support is a complementary wellness support offering and is not intended to diagnose, treat, cure, or replace medical, psychological, or emergency care.

yes

no

I understand that experiences vary from person to person and that this work is approached gently and without guaranteed outcomes.

yes

no