Somatic Bodywork Intake Form

Somatic Bodywork Intake Form

The following confidential information will be used to help plan safe and effective Bodywork/Somatic sessions. Please answer the questions to the best of your knowledge.
Name*
Address*

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Emergency Contact

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Emergency Contact's Phone Number
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Relationship to you:
Medical History and Goals

Please help me to better serve you by taking a few minutes to provide this information. For any questions you would answer 'yes', please give a short explanation
Please check any condition listed below that applies to you:
Please explain any condition that you have marked above, including medical tests/diagnoses. It is helpful for me to know when you started having symptoms, type of discomfort/pain, where it shows up in your body, and what makes it feel better or worse.
We will have time to talk more about this during your session.
Is there anything else about your health history that you think would be useful for me to know?

Is there anything about your family's health history that you think would be useful I should know?
Briefly describe your current health and lifestyle.
Please list the activities/capacities that you would like to be able to do or develop as a result of our sessions together. I would like for you to take some time on this section and come up with the goals that really mean something to you.
PLEASE READ ENTIRELY

Alejandra Hajduk is a Somatic Experiencing Practitioner and a licensed massage therapist. She is not a clinical psychologist and therefore does not offer psychotherapeutic interventions such as clinical diagnoses and evaluations, talk therapy, prognoses, or related treatment plans. Furthermore, although she may offer referrals to qualified psychotherapeutic and/or physical therapists or medical practitioners, the client is solely responsible for consulting such practitioners for any psychological or physical ailments they may have.

YOUR PERSONAL PROCESS

Alejandra offers somatic therapy that is a process-oriented. This means that the goal in the client-therapist relationship is to identify and work in harmony with the client’s own unique personal process, without attachment to a particular outcome and within the client’s range of tolerance. This process relies primarily on the client’s felt sense of what is true in addition to the therapist’s professional training and intuition.

CONFIDENTIALITY

The client-therapist relationship is treated with the same confidentiality as in any other field of health care. Client notes can be shared with designated individuals and organizations only with the client’s express written permission. In addition, all aspects of conversation are protected by confidentiality except where indicated by Massachusetts law (i.e., if the client expresses desire to and/or has already participated in harm—physical, sexual or otherwise—to themself and/or others that constitutes a crime).

SESSION TERMINATION

The client may terminate a session at any time for any reason. In the event that the client terminates a session, the client is still financially responsible for the full amount of the session.

YOUR BODYWORK SESSION

Sessions may or may not involve touch, and it will always/only be with consent.

Bodywork is provided for stress reduction, relaxation, relief from muscular tension, improvement of circulation and energy flow, as well as a means to support the nervous system's regulation while encouranging the client's awareness and self regualtion skills. This might include a certain amount of participation from the client during the session.

Alejandra Hajduk is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness, and nothing said by her in the course of the session(s) given should be considered as such.

It is expected that if the client experiences pain or discomfort during the session, that they will immediately inform the therapist so that pressure/strokes can be adjusted to an appropiate level of comfort.

REGARDING EMOTIONAL EXPERIENCE

At times a client may experience a surge or release of emotion during a session (e.g., crying, laughter, sadness, anger, muscle twitching, appearance of memories or images, etc.). This is normal and welcome. The client and practitioner work together so that the experience stays within the client’s window of tolerance and are supportive of the client’s particular purposes for the session.

SESSION LENGTH

The length of somatic therapy sessions varies on the preferences and needs of the client. I offer, 75, 90 and 120 minute sessions. When touch therapy and tablework are involved, sessions of a minimum of 90 minutes are recommended. Each session includes time at the beginning to discuss what the client wishes to address and sufficient time at the end to allow the client to process the events of the session and/or to feel grounded and ready to leave the studio.

LATE START

If the client arrives late to an appointment, the session will end at the originally scheduled time so that the practitioner can stay on schedule. If the practitioner starts a session late, she will make the time up at the end of the session when possible and if not, the session fee will be reduced proportionate to the amount of time lost. If the client is late more than 15 minutes to a session, they will be asked to reschedule and will be charged 100% of the session price.

CANCELLATION POLICY

The client agrees to give a minimum of 24-hours notice to cancel a scheduled session so that the practitioner does not lose potential business due to the cancellation. If the session is cancelled within:

• Less than 24 hours or No Show: The client will be charged 100% of the session price.

CHILD POLICY

Children are not permitted to accompany clients to appointments. If a client brings a child to an appointment, they will be asked to reschedule and a no show cancellation fee will apply (see Cancellation Policy).

ILLNESS OR CONTAGIOUS DISEASE

If a client arrives sick or otherwise contagious to an appointment, they will be asked to reschedule the appointment

COMMUNICATION

Communication between sessions is limited to information related to scheduling appointment, appointment reminders and payment related issues.
Please type in your initials to confirm you have read all of the above*
PERSONAL DISCLOSURE
I, First Name* Last Name* have stated all my known medical conditions, answered all questions honestly and will inform the practitioner of any relevant change in my health. I agree to waive all claims and to release and hold harmless Alejandra Hajduk LMT, SEP and The Somatic Center from any liability whatsoever arising from or related to failure to do so on my part. Furthermore, I have discussed any questions I may have regarding studio policies, client rights and Massachusetts law as stated herein and have received satisfactory answers.
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Somatic Bodywork Intake Form

Medical History and Goals