Client questionnaire and informed consent - Integrative Energy Bodywork

By completing this form, you agree that you have truthfully shared all essential information about your mental and physical health status.

All information you share in the form and in the sessions will be treated as confidential and will not be disclosed to third parties, unless you explicitly consent to this or there is a legal obligation to do so.

Full name

Email address

beispiel@beispiel.de

Phone number

VorwahlTelefonnummer

Please share your NOK/emergency contact- their name, relationship to you and contact e-mail & phone number.

Date of birth

Datum

Are you allergic to anything?

What parts of the body bother you?

Do you have any chronic diseases?

Please place an X beside any symptoms that you experience:

Do you have any history with psychological/mental health issues? If so please share what they were and what therapy/guidance you sought. Are they active or resolved? Please list all past and current diagnoses (year) below.

Do you have any history with physical health issues? If so please share what they were and what therapy/guidance you sought. Are they active or resolved? Any injuries/surgeries? Please list all past and current medical diagnoses (year) below.

Are you moving through any active trauma states currently that you are aware of? If yes, what is being triggered. How are you managing this?

What have you tried therapeutically - what has worked/what has not worked for you?

What do you expect from a session? How do you want to feel after?

What is your favorite body area to massage?

What makes you feel safe and relaxed?

What is your favorite scent?

What else should I know or would you like to share?

I understand that the sessions are drug and alcohol free (this includes in the 12 hours leading up to the session, not just the session time itself ).

I acknowledge that this can be a transformational experience & that feeling resistance and physical tension is a normal experience. I agree to not run, but to lean into this experience. I acknowledge that this is where I will experience my deepest growth. I acknowledge that this process might bring up trauma, I am consenting to this process and knowing this, am responsible for my choice to enter this experience. I understand that this integrative energy bodywork is a strictly non-sexual service, involves no sexual activities of any kind, and is always conducted with the client fully clothed. I understand that these sessions are powerful and I acknowledge the importance to clear my schedule of busyness so that there is space for healing & integration to take place.

If I have a medical condition, I have consulted my physician to ensure that participation in this physical-energetic session is appropriate for me. This type of therapy does not replace a visit to a doctor or psychotherapist.

You agree that you have read and agreed to be contractually bound by the terms and conditions in this agreement and on our website https://www.our-somatic-mind.com/termsandconditions. If you do not agree with anything in this agreement or need further clarification, please e-mail julia@our-somatic-mind.com.

Client questionnaire and informed consent - Integrative Energy Bodywork by Our Somatic Mind