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Confidential Intake & Readiness Assessment

Choosing the right level of support matters. Not every approach works for every person, and timing, readiness, and fit are important.

This brief intake helps us understand your situation, history, and goals before moving forward. It allows our team to assess alignment, urgency, and whether our individualized approach is the right next step for you or your loved one.

All information shared here is confidential and reviewed personally. Completing this assessment does not commit you to services and helps ensure that, if we move forward, we do so with clarity, intention, and the best chance of meaningful progress.

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TWO-PATH EXPLANATION (Families vs Individuals)

Below are two separate intake options. Please select the one that best fits your situation.

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For Families & Loved Ones

This form is designed for parents, partners, siblings, or close supporters seeking guidance on behalf of someone they care about. Most initial inquiries come from families, and we often begin by understanding the full picture from your perspective first.

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For Individuals Seeking Support

This form is for individuals personally exploring support for mental health, addiction, or major life transitions. It allows us to understand your experiences, goals, and readiness for a personalized, integrative approach.

Each form asks different questions to ensure we gather the most relevant information.

CAPACITY, URGENCY & NEXT STEPS SECTION​

Please complete only one form. All submissions are reviewed confidentially.

For Families & Loved Ones

Your relationship to the individual you’re seeking support for
Where is your loved one currently living?
What kind of support does your family feel you need right now?
What are your primary concerns right now?
Substance use / addiction
Mental health (anxiety, depression, mood)
Trauma or emotional dysregulation
Relapse risk
Lack of structure or motivation
Family conflict or communication breakdown
Life transition (career, identity, purpose)
Multiple concerns
Currently using substances
Has your loved one ever been in treatment for mental health or addiction?

Which of the following has your loved one tried before?

Has your loved one ever explored biological or neurological contributors?
Prior to today, were you familiar with QEEG brain mapping and neurofeedback?
Which activities resonate with your loved one or feel supportive?
Physical fitness / movement
Nature-based experiences
Ocean activities (surfing, snorkeling, skydiving, swimming)
Mindfulness / breathwork
Structure and routine
Community connection
Unsure at this time
Are you open to family involvement as part of the support process?

Due to the individualized nature of our work, availability is limited. All submissions are reviewed carefully, and placement is based on alignment, readiness, and current capacity. Submitting this form does not guarantee enrollment.

For Individuals Seeking Support

What brings you here today?
Which best describes your current situation?

If yes or unsure, which substances or behaviors are involved?

Are substances currently part of your life?
Have you ever been in treatment for mental health or addiction?

Which of the following have you tried before?

Have you ever explored biological or neurological contributors?
Prior to today, were you familiar with QEEG brain mapping and neurofeedback?
Which activities resonate with you?
Physical fitness / movement
Nature-based experiences
Ocean activities (surfing, snorkeling, skydiving, swimming)
Mindfulness / breathwork
Structure and routine
Community connection
Unsure at this time
Are you open to family involvement as part of the support process?

Due to the individualized nature of our work, availability is limited. All submissions are reviewed carefully, and placement is based on alignment, readiness, and current capacity. Submitting this form does not guarantee enrollment.

Contact

Whether you’re seeking clarity, support, or direction, we’re here. Let’s connect.

epicjourneyoc@gmail.com

760-409-7544

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