Somatic Bodywork Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
What are the primary symptoms or concerns you're hoping to address through somatic bodywork?
*
Are you currently (or have you in the past) working with a therapist for support for anxiety, depression, trauma, or other mental health concerns? If yes, how long have you been working with them and what changes / shifts have you noticed? If you have never worked with a therapist, write no.
*
Have you been diagnosed with any mental health conditions (e.g., PTSD, severe anxiety, bipolar, etc.) that are currently impacting your daily functioning? If yes, please explain. If no, write no.
*
Are you currently experiencing any of the following?
*
Intense emotional distress
Panic attacks that feel unmanageable
Dissociation or feeling “out of your body” frequently
Self-harm thoughts
Recent trauma (within the last 3 months)
None of the above
Have you ever been hospitalized for mental health concerns? If yes, when?
*
No
Yes (please explain)
Are you currently taking any medications for mental health conditions? If yes, please include what you are taking AND FOR WHAT PURPOSE
*
No
Yes (please explain)
Are you looking for support with emotional processing, trauma healing, or resolving past experiences? (If yes, I will likely suggest that you either work with a therapist before seeing me or working concurrently with a therapist)
*
No
Yes
Do you currently feel stable and resourced enough to explore body-based work that focuses on regulation and physical patterns?
*
Yes
No
I'm not sure
What does success look like for you after receiving somatic bodywork?
*
Are you open to working with the body through gentle hands-on techniques, movement, and breath?
*
Yes
No
Maybe-- I would like to schedule a phone call first
Do you have any questions for me before scheduling?
Submit
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