Somatic Work Intake Form

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Birthday *

MM

DD

YYYY

How familiar are you with Somatic Experiencing (SE) or other somatic-based practices?

Very familiar – I’ve done SE work before

Somewhat familiar – I’ve read about it or done something similar

New to it – This is my first experience with somatic work

Other

When you’re under stress or feel activated, how does your body tend to respond?

These are common nervous system responses—feel free to check any that resonate.

I feel anxious, restless, or agitated

My mind races or I have trouble focusing

I get tense, hyper-alert, or on edge

I shut down, feel foggy, or go numb

I disconnect from my body or surroundings

I feel frozen or like I can’t take action

It depends on the situation

I'm not sure

Other

When you check in with your body or emotions, where do you tend to land on this spectrum?

Feel free to mark all that apply or describe in your own words.

I often feel overwhelmed by emotions or sensations

I tend to feel blank, numb, or disconnected from my body

I struggle to name or understand what I’m feeling

I can sometimes track what’s happening in my body, but it’s inconsistent

I feel pretty connected to my sensations and emotions

Other

Do you have an allergies?

Yes

No

Have you had this experience?

Check all that apply

Physical Injuries (include concussions)

Physical Abuse

Sexual Abuse or Assault

Experience of Breathing Difficulty

Relevant Significant Medical/Dental Experiences

Motor Vehicle Accidents

Surgeries (Medical and Dental)

Relational/Developmental Trauma

Birth or Prenatal Trauma (if known)

Natural Disaster Involvement

War, Milatary

Other, List Anything Else of Note You Feel Is Important To Share

Do you have a spiritual or reflective practice that’s meaningful to you? If so, feel free to share what it looks like—whether it’s connected to a tradition, personal rituals, time in nature, or anything else that helps you feel connected or grounded.

Yes

No

No, but would like to integrate this in my life.

Have you been experiencing anxiety, depression, or a mix of both lately?

Yes

No

Have you had thoughts of suicide—recently or in the past?

Yes

No

Have you ever attempted suicide?

Yes

No

Have you ever worked with a therapist, counselor, or other mental health professional—either in the past or currently?

Yes

No

Have you been treated for any musculoskeletal issues (like chronic pain, injuries, or tension) or other ongoing medical conditions?

Yes

No

Who are the people or communities that currently support you in your life?

Check all that apply

Family

Friends

Partner

Therapist/Practitioner

Spiritual Community

Other

How would you describe your current relationship status? ☐ Single

Single

Married

In a committed relationship

In a non-monogamous or polyamorous relationship

Separated

Divorced

Widowed

Prefer to self-describe

Prefer not to say

Do you have children?

Yes

No

Please share any relevant family or caregiving history that may impact the work we do together.

If you checked any of the above, feel free to describe anything you think would be helpful for me to know—such as diagnoses, family patterns, or relational dynamics that have impacted your story.

Mother

Father

Please provide the following information for each sibling include step siblings:

Caregiver(s) / Guardians

Other

Not applicable / I don't wish to share

Please check below to acknowledge your understanding and consent:

I understand that Alicia offers Somatic Coaching and/or Somatic-Spiritual Direction and that these services are not a substitute for psychotherapy or medical care.

I understand that Alicia is currently completing advanced training in Somatic Experiencing® and integrates SE-informed principles into her somatic coaching and spiritual direction.

I understand that I am responsible for my own well-being during our work together and that I may be referred out if my needs fall outside of Alicia’s scope of practice.