Shamanic Bodywork Screening Form

Name

First NameLast Name

Email

example@example.com

Whatsapp Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

I identify as

I found you through...

In terms of self development, I am...

I would like to work on...

My experience with self-development is...

On a scale of 1-10 (one being very connected, 1 being very disconnected) describe your level of connection with your body

My body usually feels...

Have you done any tantra, embodiment work, spiritual work or bodywork before? If so, please describe.

Please describe your current habits with substances and past habits. Currently, I smoke/ don't smoke, drink/ don't drink, take medications, prescriptions, recreational drugs, any plant medicine experience, etc.

How do you feel about your body?

How do you feel about your sxuality?

How satisfied or connected do you feel with your pleasure?

Have you had any significant traumas or experiences that are worth mentioning?

My goal in working with you would be about:

What would you be experiencing, seeing and feeling as a direct result of this work?

What are the top 3 challenges you are facing?

How would like to be supported?

I have certain issues or injuries with my body that I would like to mention...

On a scale 1-10 this is my commitment level

Is there anything else you'd like to mention?

My intention in working with you is in creating a safe and supportive space to your development. In answering these questions, I get to know you better and learn how to support you better. Thank you!

On a scale of 1-10 (10 being complete understanding, and 1 being none to very little understanding), how much do you understand consent and boundaries?

Shamanic Bodywork Form