Feel Heal Reveal-New Client Intake Form

FEEL HEAL REVEAL – New Client Intake Form

Rory Sadoff, Somatic Experiencing Practitioner + Women’s Life Coach 📧 rory.sadoff13@gmail.com | 🌐www.rcscoach.com (visit for full registration)
Welcome
Hi love,

I’m so glad you’re here. This form helps me get a fuller picture of who you are the life you’ve lived, the patterns your body may hold, and what you’re longing for in our work together.

This form may take up to 10 or so minutes to complete. Give yourself time, and spaciousness to give as much detail as you feel comfortable. There’s no right or wrong way to answer simply share what feels true today. Everything shared here is held in confidentiality and compassion.
First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Location
Occupation
Relationship Status
Children (if applicable)
Emergency Contact Name & Relationship
Emergency Contact Number
Your Current Landscape
How would you describe your current season of life in a few sentences?
What feels nourishing, inspiring, or supportive in your life right now?
What feels challenging, draining, or out of alignment?
What are your current support systems (friends, partner, family, therapist, coach, etc.)?
Somatic + Emotional Awareness
How do you typically know when you’re stressed, anxious, or overwhelmed? (Physical sensations, behaviors, thoughts, etc.)
How do you typically self-soothe or regulate your nervous system?
Are there areas of your body that tend to hold tension or emotion?
What is your relationship like with rest and slowing down?
What helps you feel safe, grounded, or at ease?
History + Background
Have you worked with a therapist, coach, or somatic practitioner before? If yes, please share a little about that experience.
Are there any significant life events, losses, or transitions that have shaped you recently or in the past few years?
Have you experienced any traumatic events (physical, emotional, or relational) that you feel may be relevant to our work together?
Are you currently taking any medications, supplements, or under medical care for mental/emotional health concerns?
Do you have any current or past diagnoses that might be important to know?
Intention + Goals
What brings you to this work now?
What are 2–3 intentions, goals, or areas of growth you’d like to focus on?
How do you want to feel at the end of our work together?
What might get in the way of your growth or healing, and how can we work with that together?
Consent + Agreements
Please read and acknowledge the following by initialling below: I understand that Rory Sadoff is a Somatic Experiencing Practitioner and Women’s Life Coach, not a licensed psychotherapist. I understand that somatic coaching is not a substitute for medical or psychiatric care, and I will continue to consult the appropriate providers for those needs. I understand that confidentiality will be maintained within the scope of coaching ethics and professional boundaries. I agree to take responsibility for my own physical and emotional well-being during and after sessions.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

FEEL HEAL REVEAL – New Client Intake Form

Welcome

Your Current Landscape

Somatic + Emotional Awareness

History + Background

Intention + Goals

Consent + Agreements