Somatic Therapy Intake Form All information is held in strict confidence Take your time and share only what feels comfortable. Client Information Full name Date of birth Email Phone Emergency contact Emergency phone / relationship Referred by Address How long have you been experiencing your current concerns? Medical History Medical conditions or diagnoses Surgeries / hospitalizations Current medications & supplements Medication / supplementDosePrescriberReason Allergies Sleep quality Stress & Lifestyle Stress level (1 = very low · 10 = very high) 1 10 Main stressors Current coping strategies Exercise habits / frequency Diet & Nourishment Eating habits / nutrition overview Diet type Food sensitivities Cook at home vs. eat out Hydration (water daily) Connection between food and your mood or energy Spirituality & Inner Life Spiritual or religious practices Your sense of meaning and purpose Nourishing or grounding practices Mind-Body Practices Practices I do or have done (select all that apply) Yoga Pilates / movement Breathwork Meditation Mindfulness Body scan Guided visualization Prayer Dance / movement Journaling Time in nature None yet How often and how long do you practise? What helps you feel most calm or grounded? Any practices or movements to approach gently or avoid? Somatic Awareness & Body Mapping Areas of pain or tension in the body How your body responds to stress I tend to feel stress or tension here (select all that apply) Head / jaw Neck / shoulders Chest / heart Belly / gut Back Hips / pelvis Legs / feet Whole body Past therapy, bodywork, or somatic work received How connected do you feel to your body day-to-day? (0 = very disconnected · 10 = very connected) 0 10 PTSD & Trauma Symptoms — Past 30 Days Rate how much each has bothered you this past month. 0 = Not at all · 1 = A little · 2 = Moderately · 3 = Quite a bit · 4 = Extremely Unwanted memories, flashbacks, or disturbing dreams of a past event01234 Feeling very upset or having a strong body reaction when reminded of past events01234 Avoiding thoughts, feelings, or situations that bring up past experiences01234 Feeling detached, numb, or cut off from people or positive feelings01234 Strong negative feelings — guilt, shame, fear, or anger — linked to the past01234 Being on guard, hyper-alert, easily startled, or jumpy01234 Difficulty sleeping or concentrating01234 Anxiety Symptoms — Past 2 Weeks 0 = Not at all · 1 = Several days · 2 = More than half the days · 3 = Nearly every day Feeling nervous, anxious, or on edge0123 Unable to stop or control worrying0123 Feeling restless or unable to sit still0123 Becoming easily irritated or annoyed0123 Feeling afraid that something awful might happen0123 Physical symptoms — racing heart, tight chest, shallow breath, dizziness0123 Anxiety getting in the way of daily life, work, or relationships0123 Support Systems People and things that support me (select all that apply) Partner / spouse Family Close friends Therapist / counselor Psychiatrist Support group Spiritual community Pets / animals Coach or mentor Online community Mostly unsupported right now Anything about your support system your therapist should know? Session Goals & Intentions Reason for seeking therapy at this time Goals and intentions for our work together What progress or healing looks like to you Preferred session style Talking Movement Mixed Privacy & Confidentiality All personal information shared in this form and in sessions is strictly confidential and will never be disclosed without your written consent, except where required by law (e.g. risk of imminent harm to yourself or others). Name (printed) Date Electronic signature Typing your name above constitutes your electronic signature and consent to this form. I acknowledge that my practitioner is not a licensed medical professional and that somatic therapy does not replace medical or psychiatric care. I understand this form does not constitute a medical consultation. Submit intake form
