Somatic Psychotherapy Intake Form

Full name, legal for 3rd party purposes, preferred reference & pronouns

Birthday

Phone

Email

Between-session contact preferences

Phone call/voice mail

Text message

Email

Do not leave messages or text

Country/Region

Address

Address - line 2

City

Zip / Postal code

Emergency contact, relationship

Phone

Okay to contact if I am unable to reach you 24 hours after an unscheduled missed session

Employer

Occupation

Philosophical, spiritual, religious observation/orientation, challenges

Exercise, ideal and bare minimums, desired physical changes

Last medical exam, surgeries, current & past issues, preferred providers, medication, medical traumas, kindest providers

Wellness habits, meditate, yoga, journal, you rely on or wish to develop

Trauma headlines, broad strokes

Previous therapy or counseling, benefits, insights, orientations - Jungian, CBT, somatic, DBT, etc.?

What wasn't helpful? What did you learn you need? What needs to be processed?

Challenges to goal setting, consistent basic maintenance, established pro-self practices, insights gained, intuitive sense?

Benefits sought from somatic psychotherapy

What do you hope to change with somatic psychotherapy and/or co-regulating touch?

Anxiety

Depressive episodes

Sexuality

Sleep

Food relationship

Food challenges, goals

Substances

Challenges

Cognitive function

Relevant, not asked above

File upload

Heal Trauma, Deepen Connectedness,
Build Resilience, Transcend Addiction,
Cultivate Peak Performance,
One Breath at a Time

This is a Title 03

Somatic Psychotherapy Intake Form

Contact

Co-Regulating Touch.com

Heal Trauma, Deepen Connectedness, Build Resilience, Transcend Addiction, Cultivate Peak Performance, One Breath at a Time

This is a Title 03

Somatic Psychotherapy Intake Form

Contact

Co-Regulating Touch.com

Heal Trauma, Deepen Connectedness,
Build Resilience, Transcend Addiction,
Cultivate Peak Performance,
One Breath at a Time