New Client Application Form

New Client Application Form

Thank you your interest in working with me! This form helps us understand your needs and ensures we are a good fit for working together.
Section 1: Basic Information

Tell us about yourself.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.
City, State, Country
Age Range*

Under 2525–3435–4445–5455–6465+
Section 2: Your Current Situation

Share your reasons for seeking support.
What brings you to this work at this time?*
Which areas would you most like support with?*

Chronic pain or physical discomfortAnxiety, overwhelm, or nervous system regulationEmotional healingTrauma recoveryImproving movement and body awarenessIncreasing energy and vitalitySpiritual growth or integrationStress reduction and relaxationSleep improvementOther (please specify)
How long have you been experiencing these challenges?*

Less than 3 months3–12 months1–3 yearsMore than 3 years
How do these challenges currently affect your daily life?*
Section 3: Health & Somatic Awareness Background

Tell us about your background and experience.
Have you worked with any of the following before?*

Feldenkrais MethodSomatic therapyMassage therapyPhysical therapyEnergy healing (Reiki, etc.)Meditation or breathworkCoaching or therapyNone of the aboveOther (please specify)
Are you currently experiencing physical pain?*

YesNo
Where in the body are you experiencing pain?
How connected do you currently feel to your body? (1 = Very disconnected, 10 = Deeply connected)*

1

2

3

4

5

6

7

8

9

10

1 is Very disconnected, 10 is Deeply connected
Section 4: Goals & Vision

Share your intentions and aspirations.
What would you most like to change, heal, or improve through this work?*
If our work together were successful, what would be different in your life?*
What are your top 3 goals?*
Section 5: Readiness & Commitment

Assess your readiness for change.
Why are you seeking support now instead of later?*
How ready are you to make meaningful changes? (1 = Not ready, 10 = Fully ready)*

1

2

3

4

5

6

7

8

9

10

1 is Not ready, 10 is Fully ready
Are you willing to commit time to practicing between sessions?*

YesNo
Which best describes your intention?*

Immediate supportLong-term healing and transformationExploring and learning moreNot sure yet
Section 6: Logistics & Fit

Help us understand your preferences and how you found us.
Which format are you interested in?*

Private 1-on-1 sessionsOnline sessionsIn-person sessionsGroup programsNot sure yet
How did you hear about Dayana?*

YouTubeWebsiteReferralSocial mediaAngel Raphael communityOther
Is there anything else you'd like me to know?
Section 7: Agreement

Please confirm your understanding and willingness to be contacted.
I understand this work supports learning, awareness, and healing, and is not a substitute for medical treatment.*

Yes
Are you willing to be contacted to schedule a session?*

Yes
What makes you feel that now is the right time for this transformation? (Optional, but highly recommended)
Should be Empty:

New Client Application Form

Section 1: Basic Information

Section 2: Your Current Situation

Section 3: Health & Somatic Awareness Background

Section 4: Goals & Vision

Section 5: Readiness & Commitment

Section 6: Logistics & Fit

Section 7: Agreement