embodied healing Intake Form Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone (###) ### #### How did you hear about us? Option 1 Option 2 Which of the Following Services are you interested in? * Private Yoga Meditation Breath Work Somatic Healing Energy Healing - Reiki Healing Touch Healing from Trauma What specific goals and intentions do you have for our sessions? * Is there anything you'd like to share about your personal boundries, comfort levels, or concerns such as areas of sensitivity to physical touch? * Have you experienced andy physical or emotional trauma in the past that you beleive may be relevant to our work together? * Are there any medical conditions or physical limitations * Have you experienced andy physical or emotional trauma in the past that you beleive may be relevant to our work together? * Consent and Directives * I understand that the practitioner will respect my boundaries, and I am encouraged to communicate any discomfort or request adjustments at any time during our session. I acknowledge that the practitioner is not a licensed medical professional and does not provide medical or psychological diagnosis or treatment. By agreeing this form, I confirm that I have read and understood the above information, and I am providing my informed consent for somatic healing and/or yoga session. I am also aware I have right to review and discuss any aspect of this form with the practitioner before starting the sessions. I Agree I would like to Discus Further Today's Date * MM DD YYYY Preferred Date for the Session MM DD YYYY Additional Information Thank you!
