Somatic Experiencing Intake Form
Somatic Experiencing (SE™) is a naturalistic form of healing that will help you learn how to settle and release physiological activation from your body, which helps to reduce stress and return to a sense of regulation and mastery in your life. Please fill out this intake form when you have at least 15 uninterrupted minutes to give yourself the time and space for meaningful answers. THANK YOU!
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We invite you to complete this form at a pace that feels right for you. This is our first step in co-creating a safe, sacred map for your healing journey. If any question feels too "big" feel free to note "Discuss in person."
Name
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First Name
Last Name
E-mail
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example@example.com
Phone Number
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-
Area Code
Phone Number
Primary Support Person's Name and Phone Number
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Year of Birth (DOB)
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HEADLINE: What brings you to this work at this time in your life? What are you seeking?
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Part 1: The Foundation (Resources)
This section helps us understand the unique language of your body so we can safely and effectively navigate your journey.
1. When you feel a sense of ease or "okayness" in your body, where do you notice it first?
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2. What activities, environments, or people help you feel "grounded" or regulated after a stressful event? (e.g. breathwork, walking, dance, yoga)
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3. Can you describe a recent moment, however brief, where you felt a sense of connection or peace?
4. When you are under stress, does your system tend to move towards getting "Revved Up" (racing heart, tight jaw, anxiety) or "Shut Down"(numbness, heaviness, foggy, "checked out")?
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5. Where in your body do you most commonly hold tension? And how would you describe the sensation (e.g. a knot, buzzing, cold, a heavy stone)
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6. On a scale of 1-10, how connected do you feel to your physical sensations on a typical day?
7. In general, how well do you self-regulate your emotions and behaviors
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Very Well
Well
Neutral - I can't answer strongly either way
Not Well
Very Poorly
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Part 2: The Map (Health & Nervous System)
How would you describe your overall health?
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Great
Less than ideal
OK
Poor
How would you describe your sleep?
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Great
Less than Ideal
OK
Poor
How would you describe your nutrition & eating habits?
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Great
Less than Ideal
OK
Poor
How are your exercise habits? What kind of exercise do you engage in and how often? If you do not exercise, please indicate below.
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If you have any chronic pain conditions, please elaborate below. If no chronic pain, please write N/A
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What should we know about your physical history to keep you safe?
Describe your history with therapy including what type (e.g., IFS, CBT, EMDR, couples, art) , how long, whether you are currently in therapy, and do you think the therapy has helped you.
Are you currently taking any medications for mood, sleep or focus? If so, please list type of medication and how long you've been taking them.
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Have you ever been hospitalized for attempted suicide or suicidal ideation?
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Yes
No
Are you currently struggling with suicide ideation?
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Yes
No
How often do you drink alcohol and how much?
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How often do you smoke tobacco?
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How often do you smoke or ingest cannabis?
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How connected do you feel with your family and friends?
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Very Connected
Connected
Neutral - I can't answer strongly either way
Not Connected
Very Disconnected
How connected do you feel with your local community?
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Very Connected
Connected
Neutral - I can't answer strongly either way
Not Connected
Very Disconnected
Select all the physical practices that you engage in?
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Breathwork
Cycling
Dance
Float tank
Ice Bath/Cold Plunge
Running
Skiing or Snowboarding
Tai Chi or Qi Gong
Yardwork/Gardening
Yoga
Walking or Hiking
Other
How connected do you feel to something greater (e.g. humankind, planet Earth, Source, the cosmos)
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Very connected
Connected
Neutral - I can't answer strongly either way
Not Connected
Very Disconnected
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Part 3: The Landscape (Personal History)
We recognize that the questions below touch on deeply personal and potentially painful experiences. Please know that you are in control of how much you share. If a question feels too heavy to answer in writing, you may simply write 'discuss in person' or leave it blank. We will only go where your system feels ready to go.
Please share anything in your personal experience - as an infant, child, teenager, or adult - that you feel has impacted your sense of safety and/or self-worth that may be "stuck" in your system.
If you have experienced any of the following, and feel comfortable enough to share, please check any that may apply:
Physical or Domestic abuse
Sexual abuse
Emotional abuse
Neglect/Abandonment as a child
Medical, Dental, or Surgical trauma
Motor Vehicle Trauma
Bullying
Chronic Racism
Poverty
Sudden Death of a Loved One
Other
What are your three greatest accomplishments to date?
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What are your biggest obstacles right now from living your life fully?
What is the hardest thing you've had to overcome? What were the key skills, strategies or sources of support you relied on to overcome it?
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Are there specific memories, people or topics that you feel are off-limits for our sessions? Knowing your boundaries helps us honor your pace.
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Part 4: Informed Consent and Agreements
I am the expert of my own body. I have shared what feels safe to share today, and I know I can update or change my boundaries at any time.
I understand
The practitioners of Mind, Body, and Seoul Partners are not clinically licensed mental health professionals and cannot diagnose, treat, or cure any disease including mental health disorders. Our goal is to create a safe and supportive space to allow your nervous system to be the expert healer
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I understand
As part of SE, you may experience challenging feelings, images, thoughts, sleep disturbances, and unfamiliar or uncomfortable body sensations. Such reactions are common and can be attended to during our work together. Furthermore, as with any stress reduction treatment, there can be no guarantee that you will reach your goals. That said, many people report that SE has helped them tremendously and has created positive change in their lives.
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I understand and agree
Everything that you share with Mind Body & Seoul will remain confidential. If you chose to have a virtual session, however, please know that online communications are never fully secure.
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I understand and agree
On occasion, and only with your consent, will we offer touch for grounding support, containment, mobilization, or awareness building. You will always be asked before being touched and have the right to decline at any time
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I understand and agree
Sessions begin at the time of the scheduled appointment. Payment is due at the time of service. If you need to cancel or reschedule an appointment, you must give at least 24 hours notice to avoid a $50 cancellation fee
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I understand and agree
Are you interested in learning about other healing modalities we offer? If so, check all that apply:
Elemental Rhythm Breathwork
Yoga and gentle movement
Plant Medicine work
MIcrodosing
Anything else you would like for us to know?
By typing your full name below, you agree to the contents of this document and that all of the above information is true and accurate.
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