NEW CLIENT INTAKE FORM I’m so excited to begin our work together! Please fill out this form at least 24 hours before your first session so I can best support you. Name * First Name Last Name Email * Birthdate * MM DD YYYY Gender identity and pronouns What are your strengths or favorite qualities about yourself? * When do you feel the best in your body? What types of activities are you doing, or how are you living when you feel best in your body? * What resources and support systems do you have in your life? (i.e., therapist, friends, family members, pets, objects, places, etc) * What is your biggest challenge or obstacle right now? * How do you think somatic work could help you with this? * What do you desire your life to look and feel like from our time working together? * How would you prefer to receive communication from me? Straightforward and direct Gentle and soft A mix Not sure Which feels familiar? * I feel safe with you and others, including myself. I feel like I need you near me, and I don't really like being alone. I would prefer not to rely on anyone, I can do it myself. I feel confused about whether or not I feel safer with you or without. Which feels familiar? * It’s easy for me to cognitively visualize during meditations. I can’t visualize during meditations, everything just goes black. I can’t visualize very well but I can sense/feel in my body. I'm not sure. On a scale of 1 - 10, 10 = high, how would you rate the quality of your life today? * On a scale of 1-10, 10 = high, what is your current level of stress (on average)? * How do you typically support yourself when your stressed? * On a scale of 1-10, 10 = high, how ready do you feel to begin this work? (note: resistance is normal) Which of the following appeal to you? (Pick as many as you'd like) * Ongoing nervous system coaching and education Somatic Experiencing® Somatic Parts Work Attachment-focused healing Resolving trauma in the body Building stress resilience Resourcing and grounding practices Self-regulation techniques Somatic self-touch Somatic boundary work Gentle breathwork practices Accountability/check-ins via Voxer Please share anything else you'd like me to know. * Agreements In order to enhance the coaching relationship, the Client agrees to communicate honestly, be open to feedback and assistance and to create the time and energy to participate fully. We both understand that we will communicate in a direct, honest way – giving clear feedback from an empathetic and supportive place. Client and coach agree to take responsibility to show up fully for the coaching process. If anything we do together doesn’t work or feel right, you commit to bring it to my attention to shift and best support your healing process. Client and coach agree to create safe space. You agree to minimize distractions by silencing your phone and/or computer and using the bathroom before we start. Client and coach agree to be on time for our sessions. If you are unable to make a scheduled session, you agree to give a minimum of 24 hour notice. Except in cases of illness or emergency or unless otherwise agreed upon, less than 24 hour notice will result in full charge for that session. Coaching fees are nonrefundable. If Coach is unable to complete the agreed upon sessions, you will receive a refund for unused sessions. You have the right to discontinue the coaching relationship at any time. All sessions are conducted via Zoom, and you’ll receive the link to our meeting via scheduling email. When it’s time for our session, click the link to join and wait for our meeting to begin. Should we encounter technical difficulties, I’ll call the listed number to continue via phone. Disclaimer & Waiver Alyssa is a trauma-trained somatic and nervous system practitioner. She is currently a Somatic Experiencing® trainee and has a certification in Trauma-Informed Breathwork and also has training in Somatic Parts Work, Somatic Stress Release™, Polyvagal Theory-focused support, and Attachment Theory. Alyssa is NOT a licensed therapist, counselor, medical provider, or mental health professional, and she does not diagnose or treat mental health conditions, chronic illnesses, or medical concerns. As such, these sessions are not a substitute for traditional therapy, counseling, or mental health treatment. I understand and agree that I am fully responsible for my well-being during my coaching sessions, and subsequently, including my choices and decisions. I understand that all comments and ideas offered by my Coach are solely for the purpose of aiding me in achieving my defined goals. I have the ability to give my informed consent, and hereby give such consent to my coach to assist me in achieving such goals. I understand that my Coach will protect my information as confidential unless I state otherwise in writing. If I report child, elder abuse or neglect or threaten to harm myself or someone else, I understand that necessary actions will be taken and my confidentiality agreement limited in this capacity. Furthermore, if my Coach is ordered by a court to provide information or to testify, she will do so to the extent the law requires. I understand that the use of technology is not always secure and I accept the risks of confidentiality in the use of email, text, phone, Zoom and other technology. I hereby release, waive, acquit and forever discharge my Coach, any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by my Coach as a result of the advice given by my Coach or otherwise resulting from the coaching relationship contemplated by this agreement. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents. I have read and fully understand the agreement and information outlined above. * First Name Last Name Date MM DD YYYY Thank you—your form has been received. See you soon!