Brooklyn MindBody Collective intake form for PractionerAlicia Divers

Thank you for booking a Consultation Call with Brooklyn Mind Body Collective.
Please take the time to fill out his form before our call together.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

What services are you interested in?

Somatic Coaching

Somatic Experiencing

I'm not sure, I'd like to explore.

How familiar are you with somatics?

Would you consider yourself a spiritually oriented person? If so, how important is it to you that your spiriutlaity is integral part of our sessions together.

I am a certified Enneagram professional and sometimes if clients are famliar with enneagram work, they like to incorporate if into their sessions. Is this something you would be interested in doing? If so, do you know your enneagram number?

What are you hoping to get out of our sessions together?

Are you currently under any other therapist, psychologist, counselor, etc...? If yes, please describe.

Somatic Work is effective week to week therfore it is important that

Somatic work is most effective with consistency. Weekly sessions help build momentum, deepen body awareness, and support the nervous system in creating lasting change.

Yes, I can commit to weekly sessions

I’m interested but may need some flexibility

I prefer bi-weekly sessions

I'd like to discuss in Consult

I’m unsure and would like to discuss this during our consultation

Is there anything else you'd like me to know?

This is your space to share any additional thoughts, questions, or information that might help me understand how to best support you.