<p>Somatic Experiencing Intake. </p><p>This is confidential information and for me to better understand your stressors and coping mechanisms. The information is not shared.</p><p>Name______</p><p>Email______</p><p>Phone______Alternate______</p><p>Preferred means of contact Email ☐ Phone ☐ Text ☐</p><p>Emergency Contact and phone ______</p><p>General History</p><p>List any hospitalizations and surgeries. Include dates or age when this occurred. ______</p><p>List diagnosed conditions ______</p><p>Describe any pain you are having (injuries or other) – include date of onset if possible. ______</p><p>Page 1 List medications, including non-prescription or street drugs you are presently taking (not mandatory to answer this.) ______</p><p>Describe your sleep patterns. ______</p><p>Describe your emotional state and your general energy. ______</p><p>What is your occupation? ______</p><p>What do you do for fun, health and relaxation? ______</p><p>Include any other information that may be helpful. ______</p><p>What is your goal in seeking Somatic Experiencing? ______</p><p>Trauma History</p><p>Page 2 Fetal Distress (your birth) Yes ☐ No ☐______</p><p>Premature Birth Yes ☐ No ☐______</p><p>Birthing Trauma (as a mother) Yes ☐ No ☐______</p><p>Verbal Abuse Yes ☐ No ☐______</p><p>Physical Abuse Yes ☐ No ☐______</p><p>Sexual Abuse Yes ☐ No ☐______(including rape)</p><p>Lived in the presence of abuse or violence Yes ☐No ☐______</p><p>Other inescapable attacks Yes ☐ No ☐______</p><p>Mugging or entry of home Yes ☐N0 ☐______</p><p>Attempted assaults Yes ☐ No ☐______</p><p>Mental Illness Yes ☐ No ☐______</p><p>Car accidents Yes ☐ No ☐______</p><p>Injuries or burns that took a long time to heal Yes☐ No ☐______</p><p>Illnesses of note Yes ☐ No ☐ ______</p><p>Near drowning or suffocation (include choking) Yes ☐ No ☐______</p><p>Someone close to you dying Yes ☐ No ☐______</p><p>Been involved with a natural or unnatural disaster Yes ☐ No ☐ ______</p><p>Page 3 Check box next to what feelings apply</p><p>☐ 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</p><p>☐ Do you have ☐ Are you easily ☐ Often think ☐ night mares? startled? about illness?</p><p>Consent</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>Page 4 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.</p><p>Acknowledgment and Release</p><p>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.</p><p>Signature Guardian (if under 15)</p><p>Date</p><p>Page 5</p>