Client Intake & Assessment

Name *

First Name

Last Name

PHYSICAL HEALTH II *

Do you have a history of burnout / adrenal fatigue?

Yes

No

MENTAL HEALTH I *

Check all that apply

I have successfully completed therapy before

I have years of experience with healing work

I have experience with breathwork or other somatic/emotional healing modalities

I have attended plant medicine ceremonies

I regularly use recreational drugs

I was diagnosed with a severe mental health disorder (such as Addiction, Depression, PTSD, Bipolar, Schizophrenia)

I take prescription medication for mental health

Other

MENTAL HEALTH II *

I UNDERSTAND THAT THIS IS A DRUG AND ALCOHOL FREE SESSION (this includes in the 12 hours leading up to the session, not just the session time itself)

I accept

I don't accpet

NERVOUS SYSTEM II *

My main cause(s) of nervous system dysregulation is/are:

Food

Relationships

Stress

Not having a regulation strategy

Emotional Trauma

Addictive behaviors

All of the above

Other

NERVOUS SYSTEM IV *

How frequent are your emotional triggers?

Once a week

Once every 3 days

Approx. everyday

Multiple times per day

NERVOUS SYSTEM V *

What is the duration of your emotional triggers?

Once I'm triggered it lingers for days

It occupies me the whole day

A couple of hours and then my mood will normalize

I frequently shift it, so it only lasts generally no longer than an hour

EMOTIONAL AGREEMENTS I *

I let go of the expectation that this session will save, fix or heal any of my problems or symptoms for me.

Yes

No

EMOTIONAL AGREEMENTS II *

I understand that these sessions cannot take my difficult emotions from me. They can only help me to face the things I didn't have the courage to face before.

Yes

No

EMOTIONAL AGREEMENTS III *

I acknowledge that these processes may bring up deep emotional release, physical tensions and traumas. I acknowledge that I am consenting to this process and knowing this, am responsible for my choice to enter this experience.

I accept

I don't accept

ADDITIONAL AGREEMENTS I *

I understand that this session is powerful and I acknowledge the importance to clear my schedule of busyness so that there is space for healing & integration to take place after the session.

I accept

I don't accept

ADDITIONAL AGREEMENTS II *

I understand that my life cannot change unless I take ownership of my own emotional process and the decisions I make in life.

Yes

No

ADDITIONAL AGREEMENTS III *

I understand that the real life changing work is done at home.

Yes

No

ADDITIONAL AGREEMENTS IV *

I am ready and willing to go through a deep emotional process.

Yes

No

ADDITIONAL AGREEMENTS V *

I am aware that this may bring up destabilizing emotional material such as helplessness or powerlessness that could potentially linger up to a couple days/weeks after the session.

Yes

No

ADDITIONAL AGREEMENTS VI *

I am aware that as part of a normal process, symptoms and emotions can sometimes get worse before they get better.

Yes

No

ADDITIONAL AGREEMENTS VII *

I am mature enough to witness and hold myself in these difficult states. I trust that all of this is part of the healing process and I will reach out to my emotional release guide if I need assistance.

Yes

No

ADDITIONAL AGREEMENTS VIII *

I will not isolate myself in my own process and I will communicate when I need assistance.

Yes

No

ADDITIONAL AGREEMENTS IX *

I am aware that the emotions released in the session could trigger stories, projections and drama within me. I will attempt to discern my own protective patterns.

Yes

No

ADDITIONAL AGREEMENTS X *

I feel safe and comfortable with my emotional release guide.

Yes

No

ADDITIONAL AGREEMENTS XI *

I am ready to trust and surrender to my body intelligence to go through this deep process.

Yes

No

ADDITIONAL AGREEMENTS XII *

I will provide feedback after the session for my release guide.

Yes

No

WAIVER *

I acknowledge that the therapy activities in which I will engage as part of our sessions have risks. By my participation in the therapy, I hereby assume all risks and all responsibility for any loss or damage. I voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify the Therapy Provider and their representatives, employees, and assigns from any and all claims, actions or losses which may arise out of the therapy. I agree to cooperate fully, to participate in all therapy procedures, and to comply with the plan of care as it is established. If I have any medical conditions, I have consulted with my physician to make sure that physical therapy is appropriate for me to participate in.

I accept

I don't accept