Client Application – The Subconscious Codex

Client Application Form

A client only has to fill out this Client Application once.

Privacy: Information you share within this Client Application will never be shared.

Client Health & Safety Commitment: For safety reasons, this Client Application will take information about your current mental and physical health that may impact the relationship to nervous system regulation.

Individuals must be 18 or older to apply. Services are provided in English. We are not currently taking clients currently undergoing extreme mental health symptoms; extreme disassociation, overly frequent nightmares, substance abuse, addiction, compulsion, hyper-fixation, excessive mood swings, excessive rumination, psychosis, or any symptom that impacts the nature of the mind. Our sessions are not a replacement for therapy or professional mental health services. The following topics and conditions can not be serviced or discussed within your session: (1) Mental Health Diagnosis, (2) Information On Mental Health Symptoms, (3) Intrusive Thoughts, (4) Hyper-fixation, (5) Excessive Rumination, (6) Compulsion, (7) Excessive Disassociation, (8) Addiction, (9) Depersonalization & Derealism, (10) Providing Therapeutic Services, (11) Behavioral Changes Due To Brain Damage, and (12) Abusive Relationship Dynamics.

First Name

Middle Name

Last Name

Perferred Nickname (Optional)

Phonetic Name Pronunciation

Please confirm your email.

Your Client Application will be reviewed within the next 1-3 business days. If you do not receive any information delivered to your email within this time frame, please check your spam folder.

Phone Number

Birthday

What are your perferred pronouns?

She/Her He/Him They/Them

What time zone are you in?

Zoom Username

Please confirm your Zoom username.

Are you above the age of 18 years old?

Yes No

We are only accepting individuals 18 or older at this time.

Today's Date

Let's define your current session goals. These can be subject to change as we journey through sessions and the goals transform or mature. Inform me a little about what you are looking for in life right now.

Do you have any personal, social, or career goals you would like to inform me of?

What is your biggest challenge when it comes to developing yourself?

What are you most excited about when coming into a session?

What would success look like to you after working together?

Is there anything else that you find important for me to know about yourself?

The following section will go over mental and physical health information as it applies to nervous system regulation coaching. Be sure to answer the following questions honestly. Your answers will remain private and never be shared. This is exclusively to ensure that our experimental services do not fall under the work that a mental health practitioner better serves.

Is it okay to do a somatic, metacognition, or nervous system regulation session if you are diagnosed with a mental health disorder?

This depends on where you are at with your mental health support and whether you have access to a mental health professional and medication you feel you are benefiting from. Secondly, it would be important to understand the current fragility of your mental health condition. If you are currently experiencing mood swings, extreme disassociation, depression, compulsion, hyper-fixation, prone to addiction, or any more extreme mental health symptom it would be best to continue your relationship with a professional mental health practitioner.

Do you have any history of mental health?

Are you currently seeing a mental health professional, therapist, practitioner, or coach?

Yes No

Are you currently undergoing addiction, extreme disassociation, overly frequent nightmares, substance abuse, compulsion, hyper-fixation, excessive mood swings, excessive rumination, or ever experienced psychosis?

Yes No

Are you currently undergoing or are impacted by health issues with the eyes, seizures, high blood pressure, or a history of heart issues?

Can you hear an audible internal monologue, have active internal mental imagery, and have a moderate ability to feel nervous system signals, emotions, and sensations?

Yes No

Do you have access to any of the following materials to have an ongoing Nervous System Workbook throughout our sessions?

Tablet & Digital Pencil Blank Notebook

If we need to send you materials mid-session, what is the quickest way to get you these materials?

Phone Email

How comfortable are you using written materials to express yourself?

1 being it does not come naturally to you and 10 being it comes naturally to you.

Session materials are not always used in sessions. Materials are only used if they apply to a Client's goal development.

I confirm.

How comfortable are you exploring and expressing your emotions?

1 being not comfortable and 10 being very comfortable..

How comfortable are you in exploring and expressing mental imagery and visualizations?

1 being it does not come naturally to you and 10 being it comes naturally to you.

We take clients in at various levels of experience. If you are new to these concepts, welcome. We are happy to exploring with you. If you are seasoned in nervous system regulation, thank you for continuing your exploration with us here at The Subconscious Codex.

How comfortable are you learning on-the-spot and applying new information as you go?

1 being it does not come naturally to you and 10 being it comes naturally to you.

What is current level of education around Nervous System Regulation and Applied Polyvagal Theory?

1 being it is new to you and 10 being you are extremely familiar with the concepts.

Session Pillars

There are three main pillars to sessions: (1) goal-oriented nervous system regulation, (2) Shaina Scott's experimental discussion, and (3) metacognition strategy integration. Not all sessions include all three pillars. A client will establish their goals for a session, and we will select the pillars that best develop a client's goals. This may include one to three pillars in any given session. Each session varies. Using all three session pillars is time-permitting and only used if applicable to a client's goal.

Routine Coaching Commitment

In traditional coaching, we recommend having multiple sessions to see long-term progress on your goals. A single session can provide ample helpful guidance and deep education on your nervous system around your goals. Hitting the confirm buttons allows us to ensure you understand that one-time versus multiple-time commitments will see different result levels within your sessions.

I confirm.

Goal Over-Stimulation & Disconnection

In sessions, we are dealing with your real-world problems, challenges, and deep wants in life. Sessions are a safe place for your honest sensations and discussion - that is a part of the process. Over-stimulation, vulnerable emotional processes, memory recall, resurfacing outdated unprocessed emotions, and uncovering new things to work on in your self-development are normal parts of nervous system regulation sessions. We will regulate it as we go. It is part of the process to be willing to face yourself at a deeper level, and we honor client's individual pace. Even though a client may come in with a specific self, social, or career development goal in mind, stabilizing the nervous system may have unexpected results on what the true core unconscious resistance is, which can be surprising and at first feel unrelated to the core arc goal. This is normal, we will always come back to integrating your goals.

I confirm.

Understanding Coaching Vs. Therapy

Nervous system regulation coaching is not a substitute for therapy and does not treat mental health symptoms. Shaina Scott is trained in trauma-informed coaching through The Embody Lab. A trauma-informed coach means this allows your coach to be aware of the following:

A. How trauma impacts the nervous system.

B. How to handle a client that suddenly gets overstimulated when they were not expecting to.

C. How to listen to (not diagnose or treat) real-world experience, meaning not ignoring clients' life stories, including traumatic stories, in the understanding and strengthening of a client's goals. Your coach is not trained to diagnose or heal these trauma stories. Your coach is trained to regulate your nervous system in the present moment towards your goal.

Therapy focuses on diagnosing and treating mental health symptoms. Therapy also involves breaking down patterns within your traumas. Coaching does not involve the diagnosis or the treatment of mental health symptoms. You may inform a coach about your past, and your past may come up organically in sessions. We will instead use that information to paint a picture of your current nervous system and apply regulation techniques in an informed way. Your stories inform a coach on how to better serve your regulation needs. Your stories are not analyzed to treat mental health symptoms or diagnose you in any way.

As an example, anxiety is a sensation many people feel. However, this does not mean that everyone has an anxiety disorder. Constant states of anxiety or extreme panic attacks need to be treated by a mental health professional. However, anxiety that is not constant or extreme can be effectively treated in nervous system regulation coaching. Dysregulated nervous systems can display symptoms that are often similar to mental health symptoms. However, a dysregulated nervous system is not necessarily a pathological issue and can happen to anyone. The difference is in severity, diagnosis, cognitive distortion, identity distortion, reality distortion, and other symptoms that make nervous system coaching currently unsafe until therapeutic treatment is pursued.

I confirm.