Somatic Liberation Session Intake

Name*

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 CodePhone Number

Self-Identified Gender

Nonbinary, Cisgender Female, Cisgender Male, Genderfluid, etc.

Assigned Sex At Birth

Male, Female, or Intersex

Preferred pronouns

She/Her, He/Him, They/Them/Theirs, Ze/Hir

What is your comfort level expressing your needs and desires? (1 being a lot of fear or resistance and 10 being complete ease and confidence)

What are some self-identified blocks to acheiving the fully actualized life you desire

Describe current challenges you are seeking to receive support around:

What is your current comfort level with touch in a session?

We will discuss prior to as well. Boundaries can develop at any moment and will be honored.

What are your hopes around your experience with a session?

You'll be guided to notice sensations, thoughts, memories, images, that present as material the body decides in the moment to raise for being present with.

Potential concerns for a session

Your clear boundaries for a session

Examples: Physical distance, areas that are triggering to touch, request for no touch, and/or physical needs for comfort, 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.)

Known emotional trauma in your history you would like me to be aware of prior to a session?

Are you aware of bodily trauma, sexual or otherwise? If you would like me to be aware of this prior to a session, briefly share.

It is okay to discuss this in-person instead of via the form.

Do you have any sensitivities, physical limitation, injuries, or restrictions you would like me to be aware of?

Describe any mental, psychological or physiological conditions, diagnosed or otherwise, that might impact your session:

Other information that may be useful for me to know

Somatic Liberation Session Overview

1. Determining Fit

After you complete the intake form, we’ll connect to ensure we’re a good match.
Either of us may discontinue working together at any time if it doesn’t feel aligned.

2. Scheduling & Payment

Once we decide to proceed, we’ll confirm a session date/time.
Payment is due on the day of the session, prior to beginning.
48 hours’ notice is required for cancellations, except in cases of illness or emergency.

Session Format & Boundaries

Discussion & Education

We’ll begin with a brief conversation to clarify your intentions, boundaries, needs, and concerns.
You’ll have the chance to ask questions and express what you hope to gain from our work together.

Environment

We may work on a bed, floor, or massage table, using cushions as needed for comfort and support.
In-person sessions are fully clothed. Virtual sessions are also available and effective.

Consent & Comfort

Your boundaries and consent are paramount. You can pause or stop at any time.
We’ll hold eye contact to reduce dissociation and facilitate a calm, trance-like state if that feels appropriate.

My hand placement may hover above or gently rest on areas like the throat, heart, solar plexus, sacral region, or pelvic bowl—only if you feel safe and resourced to explore this.
Embodiment Practices

We’ll begin with grounding or gentle stretches to shift from busy thinking into intuitive body awareness.

I’ll open a sacred container, guiding you to notice sensations, emotions, or urges arising in the moment.

You may feel drawn to make sounds, movements, or say words—honoring your body’s subtle prompts.

Integration & Grounding

Sessions vary: some are subtle and insightful, others more cathartic. There’s no right or wrong experience.

After the active portion, we’ll spend a few minutes integrating and grounding before you re-enter daily life.

Deeper healing often unfolds with multiple sessions; you may email me between sessions with any reflections that come up.

Rates & Session Length

Virtual (45 minutes): $167

In-Person (60–90 minutes): $279Typically, we’ll spend ~20 minutes in conversation and grounding, ~20–40 minutes in somatic exploration, and ~15 minutes integrating.

Disclaimer

These sessions aim to support healing, awakening, and reclaiming wholeness. They do not replace therapy, medical examinations, or diagnoses.
I am not licensed to diagnose, prescribe, or treat physical or mental illnesses.
Please inform me of any relevant conditions and update me if anything changes. I am not liable for any undisclosed health issues or conditions.

Thank you for taking the time to review this information. If you have any questions or concerns, feel free to reach out before our session. I’m here to create a safe, empowering environment for your somatic exploration and transformation.

Preventive Measures to Reduce the Spread of COVID-19 (and Other Pathogens)

I acknowledge that Sandra Galiwango (“Sandra Rose”) cannot guarantee that I will not be exposed to or infected by the Coronavirus/COVID-19 (or any other illness). I understand that exposure or infection may result from the actions, omissions, or negligence of myself and others, including Sandra Galiwango, other practitioners, and/or other clients and their families.

I voluntarily seek services provided by Sandra Galiwango and recognize that by doing so, I am increasing my risk of exposure to the Coronavirus/COVID-19.

At the time of my appointment, I attest to the following:

I am not currently experiencing any symptoms of illness, such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, or new loss of taste or smell. If these symptoms arise, I will cancel or reschedule my appointment.

I have not been diagnosed with Coronavirus/COVID-19 without being subsequently cleared as non-contagious.

If I have any reason to doubt my health status, I understand I am encouraged to self-test prior to my appointment to reduce the likelihood of spread.

Comprehensive Liability Waiver

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, and her family, or that may otherwise arise in any way in connection with services received from Sandra Galiwango. I understand this release discharges Sandra Galiwango from any liability or claim that I, my heirs, or personal representatives may have against her with respect to any bodily injury, illness, death, medical treatment, or property damage that may result from any services provided by 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*

Date*

Date

Individual Session Intake