New Mentoring Client Intake Form

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Client information - Step 1 of 6

Before your first mentoring session

Welcome. Please take a moment to tell me about yourself before we meet. This form brings together your contact details, training and experience, and what you would like to focus on in mentoring.

Fields marked with a red asterisk (*) are required.

Allow about 20–30 minutes for brief answers. You can skip questions that do not apply; the EMK section is optional. If you need a break, choose Save and Resume Later to save your progress and return within 30 days.

Client Information

Client Name *

First

Last

Date of Birth *

Gender *

Email *

Phone *

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GDPR

Your personal data is collected ans stored securely for professional data only. It will not be shared without your consent, except where required by law. You may request, access correction, or deletion of your data at any time.

Your data is only used for the purposes for which it was collected, such as processing your requests, providing services or communicating with you.

We store your data securely and maintain appropriate safeguards to prevent unauthorised access, loss or misuse of your data.

If you have any questions about how we handle your data or if you would like to exercise your rights under the GDPR, please feel free to reach out to us via the contact page.

Emergency Contact

Phone Number to Emergency Contact

Common Information

How Did You Hear About Heart of Mervin?

Internet/Search Engine
Friend Referral
Social Media
Referral
Third-Party Review
Other

Have you done Kinesiology before?

If yes, please list where

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Your mentoring focus

With Mervin Wilk | For kinesiologists, EMK students and practitioners

Taking time to prepare helps you clarify what matters most, so we can make the most of your mentoring session and identify useful next steps.

Allow about 20–30 minutes for brief answers. Take longer if you wish.

Tick the topics that matter to you now. A few words are enough in the answer boxes. Skip anything that does not apply. The EMK section is optional. Finish by choosing your main focus in the final section.

What would you like to gain from mentoring?

Clearer direction
Confidence in a specific skill
Advice on a decision
A fresh perspective on my work
Support with a current challenge
A practical plan I can follow
Ideas for developing my practice
More ease and enjoyment in my work

Choose up to three.

Where are you now?

Training as an EMK student
Certified EMK practitioner
Practising another kinesiology method
Therapist in another modality
Starting or planning a practice
Established in practice
Returning after a break
Changing or expanding my work

Tick all that apply.

Your training and experience: methods or EMK modules, time in practice and session setting

in recent Where

What is already going well? Name a strength or a recent moment we can build on.

You can leave questions for our conversation. Brief notes are enough; you do not need to have everything worked out before we meet.

Save and Resume Later

You and your practice

Tick the areas you would most like support with. You do not need to explain every choice.

You as a practitioner

Confidence in my knowledge and skills
Recognising strengths and my next step
Developing my own practitioner style
Reflecting on intuition and impressions
Understanding and explaining my session choices
Choosing the next step when a session becomes unclear or unexpected
Integrating techniques I have trained in
Explaining complex concepts in simple language
Noticing habits I want to change
Staying present and listening fully
Self-doubt and my reactions with clients
Making good use of feedback
Growing into the practitioner I want to become

Tick all that apply.

Your practice

Session structure, flow and timing
Adapting sessions to the individual
Bringing knowledge, intuition and trained skills together
Exploring complex client situations from different perspectives
Client-led goals and useful questions
Consent and a comfortable pace
Client feedback and reviewing progress
Closing sessions, home practice and follow-up
Refining services or specialisations
Developing ideas that feel my own
Matching my skills to my client group
Forms, notes and the client experience
Responding to concerns or misunderstandings
Respecting different beliefs and needs

Tick all that apply.

Share one session, learning or business example. What were you hoping for, what did you try, and what happened?

Optional. A success, challenge or unfinished attempt can be useful. Include feedback where available and what you would like help understanding. Keep client details anonymous: omit names, initials, exact dates and identifying details. Separate what you observed from your interpretation.

Save and Resume Later

Your business and support

Choose what fits your interests, values and capacity. Skip topics that do not apply.

Your business and direction

My niche and where my work fits alongside other services
Explaining what makes my work distinctive
Recognising overlooked opportunities
A consistent identity across my communication and client experience
Website wording and the client journey
Social media that reflects my own voice and work
Feeling comfortable promoting my work
Workshops, teaching and new services
Turning what I enjoy sharing or teaching into an offering
Comparing income options: sessions, groups and reusable resources
Fees, capacity and a workable schedule
Booking, payment and cancellation systems
Partnerships and referral relationships
Choosing a practical growth strategy
Reviewing what brings suitable enquiries

Tick all that apply.

Support for sustainable practice

Scope of practice and referral decisions
Consent and responding to client distress
Privacy, records and communication
Boundaries and difficult conversations
Insurance, qualifications or membership
Practical support for working online
A manageable workload and recovery time
Finding peer or professional support

Tick all that apply.

Looking ahead 6–12 months, what kind of practitioner and practice would you like to develop?

Consider the qualities clients would experience, the work you enjoy and a manageable working week. Note any idea or decision you want help with.

We can identify questions for your training body, insurer or another professional. Mentoring does not replace required supervision, certification or specialist advice.

Save and Resume Later

Your EMK learning in practice

Optional. Complete this section only if you work with EMK. Otherwise, select Continue.

Where would revision or practice help?

Indicator muscle testing and consistency
Prechecks and their purpose
Willingness and connection procedures
Goal or context setting
Circuit retaining and stacking
Priority and modality selection
Kineasy balance sequence
Five Elements work
Meridian Rivers of Chi
Chakra Healing
Transpersonal Chakras
Aura Balancing
Emotions and client-led exploration
Age-related material and uncertainty
Remedy selection and explanation
Challenge and recheck procedures
Home reinforcement and closure
Session sheets and case-study writing
Using manuals, charts and the database
Online or group work within my training
Linking findings to the agreed goal
Knowing when to simplify or stop testing
Integrating advanced skills I have learned into a complete balance
Understanding a testing response alongside what the client says

Choose areas you have studied. We will work at your level and use your authorised course material.

Which small part would you most like to understand or practise? Add your module or manual version.

For example: explain a precheck, practise a question, or talk through a session ending. Bring your relevant manual. We can explore testing responses alongside what the client says; a testing response does not establish consent, diagnosis or historical fact.

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Our focus for the meeting

Bring your choices together. We will agree what fits the time available.

If we focus on one thing, what would make the biggest difference for you now?

By the end of our meeting, what would you like to understand, decide or be able to do?

What would you notice in your everyday work if mentoring was helping?

What kind of support would help?

Time to reflect and think things through
Experienced advice on a specific question
A clear explanation or demonstration
Time to practise, receive feedback and retry
Specific feedback on my work
Help weighing up different options
Reviewing a form, website or resource
Making a manageable action plan
Encouragement and a fresh perspective
Finding suitable further learning

Tick what fits.

What helps you learn and receive feedback? What should we adapt or approach with care?

Tell me about language or access needs, pace, or anything you prefer to discuss privately. You are welcome to disagree or suggest a different approach.

Anything we should agree together?

Confidentiality and how notes are handled
The scope and limits of mentoring
Contact between meetings
The pace or frequency of meetings

Tick all that apply.

Together, we will agree a manageable next step and how to review what you learn.

Thank you for taking time for yourself and your work. Keep client details anonymous and bring your reflections to our mentoring conversation.

Signature Statement

By submitting this form, I confirm the information I have provided is true and accurate to the best of my knowledge.
I have read and understood the Policies and Procedures of Heart of Mervin (opens in a new tab), and I am aware of both my rights and responsibilites.
I aknowledge that Mervin Wilk does not diagnose or treat medical conditions, and that the services provided are not substitute for medical care.

Confirmation (required) *

I am aware I confirm the signature statements by submitting this form.

Please tick this box to confirm the signature statements before submitting your form.

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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