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Intake form
Please fill out all of the following information before our session together. Questions? Email me at
sol19@ymail.com
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Email
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Your email
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Your full name and preferred pronouns:
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Address: Street
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Address: City
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Address: State
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Your answer
Address: Zip code
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Your answer
date of birth
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DD
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YYYY
Astrology Chart information: Place of Birth
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Your answer
Astrology Chart information: Birth time . (exact time)
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Your cell phone number:
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Your home phone number:
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Your answer
Your occupation:
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Your emergency contact name:
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Your relationship status?
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Number of Children and ages
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Your answer
Your emergency contact phone number:
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Your answer
Are you presently taking any medications, herbs, supplements?
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Yes
No
If yes, please list name and reason for medications, herbs, supplements:
Your answer
Do you smoke or self-medicate with any substance(s)?
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yes
No
If yes, please explain type and use
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Have you had a recent major surgical procedure, hospitalization or injury?
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Yes
No
If yes, please explain
Your answer
Have you ever received ...
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(Check all that apply)
Movement Therapy
Polarity Therapy
Quantum Energy Medicine
Astrological Counseling
Reiki
Perinatal Therapy
Somatic Therapy
Therapeutic Bodywork
BodyMind Centering
Somatic Psychotherapy
Other:
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Are you currently seeing a Chiropractor, Physical Therapist, Physician, Psychiatrist, or other Alternative Practitioner for an ongoing issue?
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Yes
No
If yes, what is the issue and what sort of practitioner are you using?
Your answer
Are you sensitive or allergic to any scents or oils?
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Yes
No
Any other known food/drug allergies?
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Your answer
Do you have any of the following today?
skin rash
cold/flu
open cuts
severe pain
anything contagious
injuries/bruises
none of the above
Other:
What are your intentions for this session?
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What brings you ease, joy, inspiration, or sense of belonging in your life? What are some resources that you can tap into (from any realm - seen or unseen)?
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Your answer
Do you have animal companions in your life?
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Yes
No
Do you have a reflective or mind/body practice of any kind?
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Yes
No
What do you do for movement/exercise?
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What is your stress level?
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Low
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High
Are you currently under an emotionally intense period or transition in your life? How are you supporting yourself or managing during this time? List some of your resources.
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Your answer
Have there been any big changes or losses recently in your life? (Living situation, work, family, relationships)
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Your answer
If you know about your birth process, please share any information you can; complications, trauma, medical interventions as well as what was happening in your family emotionally or psychologically.
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Do you have a history of mental, emotional, physical or sexual abuse? Please share whatever feels right around this topic.
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