Client Intake Form

Welcome and thank you for your interest in Somatic Healing!

The information provided on this form will be used solely to support your therapeutic process. If at any time it feels overwhelming or you do not want to answer the questions you may stop doing so. Detailing one's history, no matter how basic it seems, can trigger a multitude of emotions and it may be more harmful to push through just to complete the form. There will always be an opportunity to revisit the questions at a latter time and in some instances these prompts can be a jumping off point for the work we do together. Anything that is provided here is included under the umbrella of my professional confidentiality clause.
Please indicate the category(ies) you identify with below. If none of these characterize your situation then I may recommend you to seek another practitioner.*

Acute injury due to athleticsCompetitive athlete focused on preventing injurySeeking reduction of dysfunctional patterns (posture, stress) that lead to chronic painReferred by health professional for specific treatment
Referred by (if applicable):
Name*

First NameLast Name
Cell phone number*
Used for reminders and communication but never spam!
Email *
For appointment confirmation and reminders. We will not sell or spam your account.
Birthdate

MonthDayYear
Emergency Contact Phone Number
Only used in medical emergencies.
What is your primary concern or area of your life you would like to change?*
Please indicate all previous treatments tried for this injury.

massage therapychiropractorphysical therapyorthopedic consult/ images takenOther
Please describe in your own words your level of stress on the body, both physical and emotional. What do you believe has the greatest impact on these levels (ie, poor sleep, tightness or physical limitations, disassociation from sensations in the body, nutrition, work habits, etc)?
Everything affects everything in the body! Treating symptoms does not lead to pain free living.
Briefly list any surgeries or major injuries (Scar tissue can influence movement in a multitude of ways).
Habits
How many days a week do you walk for 10-45 minutes?

Never1-3 days5-7 days
How many days a week do you lift weights or get out of breath for 30 min or more?

Never1-3 days5-7 days
How many hours a day are you seated at a desk, in the car, or on the couch? An estimated minimum is 2 hours a day.

2-5 hours5-9 hours11 hours or more (1+ hrs driving, 8+ hrs workday, 2+ hrs on couch)
What is your 'work day average' number of hours of sleep you get?*

less than 6 hrs6-9 hrs9-12 hrs
Which of the following best describes your eating habits?

I eat when my body tells me I'm hungry and grab the easiest thing.I try to eat regular meals and follow some nutritional guidelines.I plan out my meals and adhere to a special diet.
In what ways do you notice your food influencing your mood or how you feel throughout the day?
In what ways do you notice your food influence your mood or day?
How much plain water do you consume regularly?

0-8 oz/day16-24oz/day32+oz/day
How much caffeine do you consume regularly? (12oz soda has 30-80mg, 8oz tea has 40-70mg, 8oz coffee is typically 90-120mg, 1 energy drink can have 200- 300mg of caffeine)

I don't use caffeineless than 100mg /day100mg- 200mg /day300mg or more /day
How much alcohol do you consume regularly?

I don't drink or drink only a few times a year1-3 drinks a week5-10 drinks a week1-3 drinks a day
The preceding habits can seriously impact your body's ability to HEAL and function. Pain relieving drugs, whether prescribed or not can also affect the pain perception and regulatory systems in the body. If you would like to discuss these areas of health please indicate yes.
What is your general availability for an appointment in the next month? I will email specific dates to you after reviewing your information.*

weekdays 8:30am-1pmweekdays after 4pmSunday after 3pmI have a rotating schedule
Should be Empty:

Welcome and thank you for your interest in Somatic Healing!

Habits