Sacral Somatic Therapy - New Client Form

Barefoot Vibes: Sacral Somatic Therapy

New Client Form
Thank you for showing interest in booking a Sacral Somatic Therapy Session with Sasha Hopkins.

Please complete this form and advise your preferred days/times for your booking. Please note room hire availability is limited with mostly Monday's being available.

Please know that Sasha treats each client as an individual and understands that everyone's needs are different. All information provided is strictly confidential between Sasha (the practitioner) and you (the client). If any of the questions are unclear or you would prefer not to answer, you may choose to leave them blank.

Venue location: Maine Road, Clontarf (address will be provided once booking is confirmed)

If you have any questions prior to completing this form please email Sasha: sasha@barefootmidwifery.com.au
Preferred day of the week*

MondayTuesdayWednesdayFriday
Preferred time*

9am-12pm1pm-4pmEither of the above
Name*
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Suburb
Post Code
Mobile*
Emergency Contact Name*
Phone*
Referred by? How did you find me?
Do you have any allergies or sensitivities that I need to be aware of? If Yes, please provide details
Are you taking any medication(s) that I need to be aware of? If Yes, please provide details
Have you had or are you currently experiencing any of the following?

LabiaplastyDifficult menstruationPainful intercourseMigrainesDiabetesVaginoplastyMenopauseEpilepsyDepressionPhobiasObsessionsEpisiotomyCaesareanBreakdownsHSV 1 or 2InsomniaNightmaresHypoglycaemiaRecurrent Urinary InfectionsADHDSensory sensitivitiesHysterectomyIndwelling contraceptive (current only)PCOSHigh/Low blood pressureRecent surgical procedure*Other
*Other, please provide details
If you ticked surgical procedure or indwelling contraceptive please share how these impact you
Are you pregnant (If yes, how many weeks)? Or have you given birth in the last 12wks?
Sacral Somatic Therapy is offered on the floor on a padded mat with bolsters and pillows for support do you have any mobility restrictions that I need to be aware of and/or do you need extra support?
Please tell me about your journey as a woman in whatever term that means to you and please share what your relationship is like with your body*
Have you received a Sacral Somatic Therapy Session or Yoni Mapping before? If so how was this experience for you?*
What has drawn you to have Sacral Somatic Therapy?*
To your knowledge have you ever experienced any sexual trauma?
Do you have any self-love or self-pleasure practices? Is this something you would like to learn more about?*
What is your intentions for receiving a Sacral Somatic Session?*
I acknowledge that a Sacral Somatic Session is for women or people with female genitalia only*

Yes, I acknowledge this
To the best of my knowledge, all the above information is true and correct*

Yes
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Date*

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Barefoot Vibes: Sacral Somatic Therapy