Somatic Experiencing® Consent & Liability
Tula Somatics | Tula Mountain Bodywork LLC
Client Information
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Email
example@example.com
Phone Number
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Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Relationship
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Health Data
Please fill out any applicable fields
Do you have any allergies?
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If yes, please specify on the field above.
Are you currently taking any medications?
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If yes, please specify on the field above.
Are you pregnant or nursing? How far along?
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If yes, please specify on the field above.
Do you have any recent or current injuries?
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If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, arthritis, etc.?
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If yes, please specify on the field above.
Current life stressors:
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Areas that need extra attention
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Goals for today’s session
Any stretches to avoid or restrictions in movement?
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Any areas to avoid including face & scalp?
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Anything else you’d like to share?
Consent and Liability Waiver
Please check boxes for consent
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If I am receiving Somatic Experiencing® (SE) or SE Touch, I understand that a massage therapist’s scope of practice specifies that they cannot actively engage in conversation or offer advice about the trauma other than to listen, support and refer.
If I am receiving SE, I understand the benefits & risks of trauma treatment: SE may offer you many benefits such as an increase in your ability to self-soothe and feel empowered. However, there may also be risks as with any treatment that focuses on healing trauma. Although SE is designed to help you resource and work with manageable amounts of discomfort, you may experience challenging feelings, images, or thoughts. Furthermore, as with any stress reduction treatment, there can be no guarantee that you will reach your goals. That said, many people report that SE has helped them tremendously and has created positive change in their lives. Learning how to reorganize “body memory” is often a vital to learning how to relax and calm your nervous system.
I understand that everything I share with you will remain confidential.
I acknowledge that all the information I have provided in this form is true and accurate and I have read, understand, and agree to the above policies.
Please Type Your Initials for Consent
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Signature of the Client
Date Signed
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Month
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Day
Year
Date
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