Welcome!

I am so glad you are here. This intake form helps me to understand more about you and design a frame for our time together. You are welcome to share as much as you like and if there is anything you prefer to not answer, you can write N/A.

Thank you,

Kate

Name

First Name

Last Name

Address

DOB

YYYY

Phone

Country

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How did you find me/this program?

What is it that draws you to Somatic Therapy?

What do you hope to get out of this program?

What practices, containers, and programs have been most helpful to you?

Please explain your current condition, symptoms and frequency. Are there are times of the day/night you feel more activated? Are you aware of specific triggers, patterns and severity of symptoms?

Please share any major accidents, injuries, relationship ruptures, and especially impactful experiences in your life. Please include approximate dates

Please list any medications you are taking and what you're taking them for.

What brings you the most ease, joy and pleasure in your life?

Is there anything else you would like to share with me?

What are your ideal day(s) and time(s) for sessions