Somatic 1x1 Session Intake Form

Body Language: Integrative Somatic Sessions
New Somatic Client Questionnaire

Please fill out and I will get back to you to set up your 1x1
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Emergency contact:

First NameLast Name
Emergency contact Phone Number

Area CodePhone Number
Background info & Goals

Please help me to better serve you by taking a few minutes to provide this information
What are your goals for our time working together?
Working with the nervous system is a slow process and Integrative Somatic Sessions may take time to notice a difference in day to day life. Are you willing to give it 3+ sessions?
Briefly describe your current wellness routine:
Do you have a consistent yoga practice, meditation practice or workout routine? If so, please describe.
What brings you joy?
Do you suffer from any pain or other ailments you would like me to be aware of?
Are you under a doctors care for this condition?

YesNo
Are you currently working with a therapist?
Have you experienced somatic therapy, guided meditation, breath work or a soundbath before? If so, please share which one(s).
What has been your experience with those modalities?
What are some of your favorite ways to decompress?

YogaRunning/ walkingGymBeing in natureJournalingMeditationSpending time with friends/ loved onesBreathworkBaths/ spa daysOther
Is there anything else you'd like me to know?
On a scale from 1-10 rate your feeling on each subject, with 1 being the lease and 10 being the most.

Are you ready to make a change to your overall well-being?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

How ready are you to dedicate time weekly to new practices?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

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Body Language: Integrative Somatic Sessions

New Somatic Client Questionnaire

Background info & Goals