Name

First Name

Last Name

I’m considering holding this container for either 3 months or 6 months. Which option feels like the best fit for you?

3 months

6 months

Unsure/Flexible

I feel connected to my body and its sensations.

1

2

3

4

5

I can recognize a strong “yes” and “no” in my body.

1

2

3

4

5

I listen to and act on my body’s signals.

1

2

3

4

5

I feel connected to my inner child.

1

2

3

4

5

I make space for play, joy, and curiosity in my life.

1

2

3

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5

I can name and identify my emotions in the moment.

1

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3

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5

I allow myself to fully feel my emotions without judging or suppressing them

1

2

3

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5

I notice my personal rhythms and cycles (energy, mood, creativity, etc.)

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2

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5

I allow myself to rest when I need it, without guilt.

1

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5

I feel connected to my sexual energy and see it as a life-force.

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5

I feel safe and comfortable exploring my sexuality.

1

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5

I express myself authentically in relationships.

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5

I express myself authentically in relationships.

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5