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1 on 1 Somatic Work Inquiry Form
Hello! If you have made it here, you are interested in stepping into a deeper space in your healing journey. Welcome and congratulations! I do not take that lightly. Please take a few moments to share in detail what brings you here so I can understand how to best support you.
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Name
Your answer
Email I can best reach you at
Your answer
Phone number I can reach you at to text or call you to set up next steps
Your answer
What Service are you interested in (Breathework, Sacred Rage, Grief Ceremony) and why?
Your answer
Have you recently experienced any type of trauma? If so, please explain
Your answer
Do you have a heart condition?
Yes
No
Maybe
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On a scale from 1-10, 10 being the most, what is your current stress level?
Your answer
Do you experience any anxiety or panic attacks, if so please explain
Your answer
Please list any questions
Your answer
Are you currently pregnant?
Yes
No
Clear selection
Are you ready to schedule your appointment and pay in full at $222
Yes
No
Maybe
I would like to place a $50 deposit and pay the balance at an agreed date before my ceremony
Option 5
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