Intake Form -

Name

First

Last

Email

Phone Number

Date of Birth

Physical Address

Emergancy Contact Name

First

Last

Emergancy Contact Number

Relationship to Emergancy Contact

What brings you to somatic therapy at this time?

What are your main goals or intentions for this work?

Have you done somatic therapy, body-based healing, or trauma-informed work before?

Yes
No

If yes, please describe your past experience.

How would you describe your general physical health?

Excellent
Good
Fair
Poor

Current medical conditions or diagnoses?

Surgeries, chronic pain, or injuries I should know about?

Are you currently pregnant, trying to conceive, or postpartum?

Do you have any allergies?

to Have trauma

Are you taking any medications or supplements? (Please list names + purposes if you feel comfortable.)

Have you ever been diagnosed with a mental health condition?

Yes
No

If yes, please describe

Are you currently working with a psychologist, psychiatrist, therapist, or coach, Who?

Have you experienced trauma that you feel comfortable disclosing? (You may answer generally.)

Do you experience any of the following: (These help me support you safely and at the right pace.)

How would you describe your stress levels?

Low
Moderate
High
Overwhelming

Do you ever feel:

Are there areas of your body where you carry tension?

Are there areas you prefer not to focus on during somatic work?

Sleep quality on a scale from 1-10. 10 being very good

Selected Value: 0

Typical energy levels on a schale from 1-10. 10 being very good

Selected Value: 0

Do you use:

Alcohol
Cannabis
Tobacco / vaping
Other substances

Have you received any COVID-19 vaccinations?

Yes
No
Prefer not to say

Have you done breathwork, yoga, massage, reiki, craniosacral, or somatic work before?

How did your body respond?

Are there techniques or approaches you prefer or want to avoid?

Are there any physical or emotional boundaries I should be aware of?

What makes you feel safe and grounded?

What helps you regulate when you feel overwhelmed? (I don't know is a perfectly valid answer)

Do you prefer sessions that are: (this will determine every session unless otherwise specified)

Any sensory preferences: (Anything that helps you settle into the space?)

Touch? (if applicable to your practice)
Music?
Silence?
Warmth / blankets?

Is there anything else you’d like me to know before we begin working together?

Intake Form

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