Welcome!

I am so glad to be deepening into this work with you. This intake form helps me to understand more about you and design a frame for our time together. You are welcome to share as much as you like and if there is anything you prefer to not answer, you can write N/A.

Please fill this out to the best of your ability before our next session.

Thank you,

Kate

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Emergency Contact

What is it that you value that brings you into this container of Somatic Therapy and depth work?

How do you most want to feel / what do you want to experience on a daily basis?

What are the biggest challenges/barriers to you experiencing that now?

What practices, containers, and programs have been most helpful to you?

Please explain your current condition, symptoms and frequency. Are there are times of the day/night you feel more activated? Are you aware of specific triggers, patterns and severity of symptoms?

Please share any major accidents, injuries, intense relationships and especially impactful experiences in your life. Please include approximate dates

Please list any medications you are taking and what you're taking them for.

What brings you the most ease, joy and pleasure in your life?

Is there anything else you would like to share with me?

What are your ideal day(s) and time(s) for sessions