intake-form | Bill Bistak

INTAKE FORM

Please take a moment to fill out the form.

First Name

Last Name

Subject

Disclaimer: Scheduled listening sessions are not medical, therapeutic, or clinical services and do not replace professional mental health treatment. No diagnoses, prescriptions, or therapeutic interventions are provided. By participating, you acknowledge this is a structured presence-based experience. Please get in touch with a qualified professional right away if you are experiencing a crisis.

IMPORTANT

By filling this form out, you agree to this disclaimer and everything described herein.

Must be over 21 years old and fluent in English.

60-minute session.

I do not offer therapy or quick fixes.

I offer what saved me: the experience of being witnessed.

First 15 minutes free.

Now taking applicants.

What we will do:

Identify your "THE OPATHIAN STATE"—that hollow feeling when emotional depths seem unattainable, yet you yearn desperately to feel.

And understand that dissociation (mental disconnection) is not weakness but a survival strategy that can become a source of personal strength.

What is happening right now that made you stop and look for this

What would it mean, if you felt heard

Is there something you have been carrying that you have not been able to say aloud because there has not been the right space for it

I want to subscribe to the newsletter.

Your Signature

All information is strictly confidential and never shared.

While transcripts are generated during Zoom sessions, they are not retained in any way unless you request them to be.

What happens after you submit:

Look in your email (or spam folder) email asking the following:

Book your session,
Pay for a full session, package, or the free 15minutes
I will send the Zoom link to your email for your booking a few minutes before we begin on the day & time you chose.