Sandra Rose's Session Intake Form

Name *
Date of Birth *

Month Day Year
E-mail *
example@example.com
May we add you to our email list to let you know about upcoming workshops and related opportunities? *
Phone Number *

Area Code Phone Number
Town/State/Country *
If you have a private clean space available, I am willing to drive to you for an additional fee within a 20 mile radius, after having a Zoom call, and confirming an agreement to work together. Alternatively, I have a private office space available local to Framingham, MA.
Occupation
Self-Identified Gender
Educational sessions and workshops are currently available for female identifying and non-binary femmes only.
Assigned Sex At Birth
Preferred pronouns
She/her, They/them, etc.
Type of Session(s) You're Interested In Exploring: (select all that apply & note that some overlap)

JourneyDance (Embodied Movement) Group Info Session Inhabiting the Body (an introductory private session) Sacred Sexual Awakening & Healing® Session (fully-clothed AH Practice®) Prenatal Support Session (with the fully-clothed AH Practice®) for those currently or anticipating becoming pregnant Local Womxn's Workshop (November 28, 2021) Processing Your Child-birth Session (with the fully-clothed AH Practice®) Mothers: Have Space Held (support for parenting challenges) Womb Clearing Session Pevlic Floor or Pelvis Related Expeience Clearning Energetic Imprints of the Yoni (Vagina) Also Seeking Couple's Intimacy Coaching (Referral)
Session Format Preference:

Virtual In-Person Undecided, possibly both
What is your availability for sessions? *
Weekday morning, afternoons, evenings, Saturdays, Sundays, etc.
How did you learn about this offering
What interests you about this kind of session? *
What are main factors contributing to your interest?
What kinds of stressors do you face?
Describe current challenges you are seeking to receiving support around:
Have you experienced a session before?

Yes with Sandra Yes, this practice with another practioner This would be the first A similar type of session with a different practioner
Do you have any hopes around your experience with a session? *
I recommend staying as open as possible as to what your body's wisdom chooses to liberate during a session. And I encourage courageous trust & honoring in and of your body to guide you.
Any current fears or concerns for a session?
Any current clear boundaries you have for a session?
Examples: Physical distance, areas that are triggering to touch, request for no touch, and/or physical needs for comfort, request for masks to be worn, etc. Note: boundaries can change at any time, and are expected to be communicated in an on-going conversation.
Forms of inner work you have explored individually
(i.e. meditation, forms of self reflection, personal practices, etc.)
Forms of inner work you have explored with support
(i.e. seminars, workshops, therapies, shadow work, emotional release work, etc.)
Have you attended a related topic workshop before?
How did the previous session(s) or workshop impact you?
Are you aware of emotional trauma in your history? If so please elaborate to the degree you feel may be relevant for the session.
Are you aware of bodily trauma, sexual or otherwise? If so please elaborate to the degree you feel may be relevant for the session.
Do you suspect hidden trauma in your history (that may exist but you may not have memory of)?
Do you have a tendancy for disassociation you are aware of? (Leaving your body as a coping mechanism.)
This is the reason we maintain eye contact during most sessions, to support remaining grounded & held here in the present moment.
Have you had surgery which could be relevant to the session in the last few years?
Do you have any scarring or sensitivity you would like me to be aware of?
Are you pregnant?
If so, how far along?
Describe any physical limitation, injuries, or restrictions that might impact your session:
Describe any mental or psychological condition, diagnosed or otherwise, that might impact your session:
Are there any other health information that may be useful for me to know
Current concerns or questions you have about a session:
First we will establish whether or not we are a suitable match for working together. At any time either party may chose to discontinue working together for any reason.

If we both decide to proceed with working together. We will start with a period of discussion and education.

Rates will be set for payment. Payment is expected the day of a session, prior to beginning.

Date and time will be set for a session. 48 hours notice for cancelation requested. Last minute cancelations for feeling sick are acceptable and encouraged.

We will explore boundaries, concerns, and hopes (which may shift and are expected be continually expressed as the session goes on.) I will express my boundaries and intentions. I will also answer any questions you have.

We will be working on a bed, floor, or massage table as we proceed with cushioned support. Space will be held for you to have your own sovereign experience, witnessed and held with presence by the facilitator. All sounds, movements, emotions, and energy are welcome as long as expressed without harm to self or other. As this part of the session comes to a close, there will be a period of integration and grounding to prepare you for re-entry into your life with a renewed perspective.

I understand that the session(s) I receive is/are provided for the purpose of healing, transmuting, awakening, and reclaiming wholeness. If I experience any pain or discomfort during the session, I will immediately inform the practitioner.

I further understand that the sessions(s) should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that my practitioner is not qualified to diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my profile and understand that there shall be no liability on the practitioner’s part for any reason whatsoever.
Additionally, I acknowledge the contagious nature of the Coronavirus/COVID-19 and that many public health authorities currently recommend practicing social distancing.

I further acknowledge that Sandra Galiwango (“Sandra Rose”) has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.

I further acknowledge that Sandra Galiwango cannot guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to Sandra Galiwango, other practioners sharing the space, and/or other clients and their families.

I voluntarily seek services provided by Sandra Galiwango and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with attestations below to reduce the spread while attending my appointment.

I attest that:

* I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.

* I have not traveled internationally within the last 14 days.

* I have not traveled to a highly impacted area within the United States of America in the last 14 days.

* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.

* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities.

* I am following public health recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

* To reduce the likelihood of spread, if I have any reason for doubt, I am encouraged to voluntarily (honor system) get tested prior to my appointment.

I hereby release and agree to hold Sandra Galiwango harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act by Sandra, other clients, or that may otherwise arise in any way in connection with any services received from Sandra Galiwango. I understand that this release discharges Sandra Galiwango from any liability or claim that I, my heirs, or any personal representatives may have against her with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Sandra Galiwango.
I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above and I agree typing my name in the box below is equivalent to my legal signature. *
Date *

Month Day Year
Date
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