Intake Form

Thank you for being here and taking the time to fill out this form. You're invited to share as much or as little as you would like. Whatever's right for you in this moment. Take your time. If anything feels overwhelming or too much, you can bring it to our sessions instead.

Relationship Status

Single

Do you have children?

Yes

Emergency Contact Name

Emergency Contact Email

Emergency Contact Number

How would you describe your childhood?

How would you describe your mother during your childhood?

How would you describe your father during your childhood?

How would you describe your relationship with your parents in the present?

Are there any life events that stand out as formative or challenging?

Do you feel a general sense of safety in your daily life?

I feel safe most of the time.

I feel safe in certain situations.

Safety comes and goes depending on context.

I often feel on edge most of the time.

I don't recognize what safety feels like.

Have you experienced any of the following?

You may choose multiple answers

Have you experienced any of the following?

Any form of abuse

Neglect or emotional abandonment

Chronic bullying or harassment

Identity-based discrimination

Growing up around addiction or mental illness

Incarceration or institutionalization

Major surgeries or medical procedures

Separation from caregivers

Death of a loved one

Sudden loss of a job, home, or relationship

Divorce or separation

War, conflict, or political violence

Financial instability

Non-consensual sexual experiences or sexual harassment

Have you experienced bullying, isolation, or discrimination?

Do you experience any of the following?

You may choose multiple answers

Do you experience any of the following?

Chronic pain

Sensitivity to light, touch, and/or noise

Chronic muscle tension

Jaw pain/Teeth grinding

Restless or difficulty staying in one position

Difficulty breathing

What helps you feel comforted and more like yourself?

When going through a hard time, what helps you cope? Choose as many as you like.

What helps you feel comforted and more like yourself?

Connecting with family and friends

Nature (being outdoors, walking, etc.)

Creative expression (art, music, dancing, etc.)

Movement (yoga, exercise, walking, etc.)

Spiritual or religious practices

Intake Form

Hey there!

Name

Date of Birth

Email

Mobile Number

Relationship Status

Do you have children?

Employment Status

Emergency Contact Name

Emergency Contact Email

Emergency Contact Number

How would you describe your childhood?

How would you describe your mother during your childhood?

How would you describe your father during your childhood?

How would you describe your relationship with your parents in the present?

Are there any life events that stand out as formative or challenging?

Do you feel a general sense of safety in your daily life?

Have you experienced any of the following?

Have you experienced bullying, isolation, or discrimination?

Do you experience any of the following?

What helps you feel comforted and more like yourself?

How would you describe your sleep patterns?

How is your relationship with food? (e.g., regular meals, restrictive eating, emotional eating)

Do you have any medical conditions or concerns?

Are you currently taking any medications? If yes, please list.

Have you sought therapy before?

What brings you to somatic therapy?

What do you hope to achieve through this therapeutic process?

Is there anything else you feel is important for me to know before starting therapy?