Preferred Means of Contact Email Phone Text

Somatic Experiencing Intake.

This is confidential information and for me to better understand your stressors and coping mechanisms. The information is not shared.

Name______

Email______

Phone______Alternate______

Preferred means of contact Email ☐ Phone ☐ Text ☐

Emergency Contact and phone ______

General History

List any hospitalizations and surgeries. Include dates or age when this occurred. ______

List diagnosed conditions ______

Describe any pain you are having (injuries or other) – include date of onset if possible. ______

List medications, including non-prescription or street drugs you are presently taking (not mandatory to answer this.) ______

Describe your sleep patterns. ______

Describe your emotional state and your general energy. ______

What is your occupation? ______

What do you do for fun, health and relaxation? ______

Include any other information that may be helpful. ______

What is your goal in seeking Somatic Experiencing? ______

Trauma History

Fetal Distress (your birth) Yes ☐ No ☐______

Premature Birth Yes ☐ No ☐______

Birthing Trauma (as a mother) Yes ☐ No ☐______

Verbal Abuse Yes ☐ No ☐______

Physical Abuse Yes ☐ No ☐______

Sexual Abuse Yes ☐ No ☐______(including rape)

Lived in the presence of abuse or violence Yes ☐No ☐______

Other inescapable attacks Yes ☐ No ☐______

Mugging or entry of home Yes ☐N0 ☐______

Attempted assaults Yes ☐ No ☐______

Mental Illness Yes ☐ No ☐______

Car accidents Yes ☐ No ☐______

Injuries or burns that took a long time to heal Yes☐ No ☐______

Illnesses of note Yes ☐ No ☐ ______

Near drowning or suffocation (include choking) Yes ☐ No ☐______

Someone close to you dying Yes ☐ No ☐______

Been involved with a natural or unnatural disaster Yes ☐ No ☐ ______

Check box next to what feelings apply

☐ Moody ☐ Manic or ☐ Depressed ☐ Irritable elated ☐ Hopeless ☐ Guilt and ☐ Anxious ☐ Sad/tearful shame ☐ Worthless ☐ Frozen and ☐ Panic attacks ☐ Shortness of breath stuck ☐ Unexplained ☐ Heart ☐ Dizzy ☐ Nausea chest pain palpations ☐ Often fearful ☐ Trembling ☐ Unexplained ☐ Phobic anger ☐ Obsessive ☐ Compulsive ☐ Impulsive ☐ Detached

☐ Do you have ☐ Are you easily ☐ Often think ☐ night mares? startled? about illness?

Consent

The purpose of this consent is to explain to you what I do and what you can expect. My belief about healing is that each of us is his or her own healer; that healing comes primarily from within you. I can assist you in your healing by doing various kinds of techniques, which will balance your energy and enhance your sense of well-being. Among the techniques that I use, include Somatic Experiencing Trauma Touch work, Early Developmental Trauma Resilience and Rolfing.

During the sessions, we may discuss the major stresses in your life, your belief system, health history, your childhood, and other issues, which have an influence on your emotional and physical well-being. These discussions will be kept confidential. At all times, your healing is your responsibility. I am available to assist you in this process as your committed listener, your mirror.

However, I am not a physician and, therefore, do not diagnose disease or prescribe drugs. I may recommend some life changes that you may implement if you choose. I do not advise you to discontinue any medical treatment you may be receiving. My work is intended to be in harmony with any other work that you undertake, including traditional medicine. Please feel free to discuss our work with your doctor or other practitioner.

I prefer to set up a regular schedule to work with you, but neither of us is under any obligation to continue the sessions. I would appreciate as much notice as possible if you have to cancel or reschedule an appointment (at least 24 hours notice). The fee is $90.00 per 75 min. People who miss an appointment must pay in advance to reschedule, and payment is non refundable within 24 hours of the scheduled appointment. Sessions start and end on time so that I can schedule the next client without causing delay or inconvenience. If you show up late, I must end the session on time, and the full charge still applies.

In signing the Acknowledgment and Release, you agree that I, Catherine Allen, may work with you in the described manner on this document. I make no promises other than those outlined. Most of my clients experience increased well-being and improvement in their condition; some have experienced complete healing. But I cannot promise you these things. I am not aware of any risks or negative side effects associated with these treatments.

Acknowledgment and Release

The Client hereby acknowledges that he or she has read the foregoing Consent Form and is satisfied that he or she fully understands the nature of the sessions and freely elects to receive the same. The Client releases Catherine Allen from any and all claims of malpractice, non- disclosure, confidentiality, or lack of informed consent. The Client freely assumes any and all risks of the treatment whether presently contemplated or hereinafter discovered. IF client is a minor, legal guardian (responsible party) shall sign.

Signature Guardian (if under 15)