Somatic Therapy Intake Form

Please fill out the form below, prior to your appointment to help me prepare for your session.

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What brings you to Somatic Therapy?

What specific goals or intentions do you have for these sessions?

Is there any particular issue or area of your life you wish to focus on during our work together?

Are there specific areas of your body where you do not wish to be touched or areas of sensitivity?

Is there anything you'd like to share about your personal boundaries, comfort levels, or concerns?

Have you experienced any physical or emotional trauma in the past that you believe may be relevant to our work together?

Are there any medical conditions or physical limitations that I should be aware of?

Consent

I understand that somatic healing sessions may involve touch and physical contact, which will always be respectful, consensual, and client-driven. I hereby provide clear written consent for touch as part of our sessions. I understand that I have the right to withdraw my consent at any time. I understand that the practitioner will respect my boundaries, and I am encouraged to communicate any discomfort or request adjustments at any time during the session. I acknowledge that the practitioner is not a licensed medical professional and does not provide medical or psychological diagnosis or treatment. By signing this form, I confirm that I have read and understood the above information, and I am providing my informed consent for somatic healing sessions. I am also aware that I have the right to review and discuss any aspect of this form with the practitioner before starting the sessions. Client Signature

Date

YYYY

Somatic Therapy Intake Form

Keelan Nightingale