Family constellation Intake Form

Family Constellations is a form of systemic psychotherapy that explores the hidden dynamics and unconscious loyalties within our family and ancestral lineages. These dynamics often shape our emotions, relationships, health, and life patterns without us realizing it. In a Constellation, we work within an energetic “field” — often using symbolic representatives or objects — to make these patterns visible. Through awareness, somatic connection, and ritual, we bring resolution to what has been entangled, allowing love and life force to flow freely again. Every constellation honors your ancestors while helping you reclaim your rightful place in the system, free from inherited pain and more connected to your authentic self.

Please take a few minutes to fill out this questionnaire which will support the focus of our session. All is an invitation.

Name

First Name

Last Name

Preferred Pronouns

What is drawing you to Family Constellation work at this time?

What feels unresolved, repetitive, or ready to shift?

Which core issue, challenge, or emotion would you like to focus on in your session?

For example: recurring relationship patterns, financial struggle, grief, anxiety, family conflict, etc.

What do you know about your family history on both sides?

Include any major events, losses, illnesses, secrets, migrations, addictions, or patterns you’re aware of.

Is there anyone in your family who was excluded, forgotten, or not spoken about?

Such as miscarried children, former partners, ancestors who died young, or estranged relatives.

Which side of your family feels most connected to your current challenge? Your mother’s or father’s line?

How do you currently feel in your body and relationships when this pattern shows up?

Notice sensations, emotions, or triggers.

What is your intention or deepest wish for healing through this work?

For example: inner peace, freedom, forgiveness, connection, understanding, closure.

Are there any limiting beliefs you’ve inherited that you’d like to work through?

Anything else you’d like me to know?

Family constellation Intake Form

Well of Being