New Client Intake Form

Your Name *

First Name

Last Name

Your birthday *

MM

DD

YYYY

Have you done Somatic Experiencing before? *

Yes

No

Confidentiality & Terms of Service Agreement *

CONFIDENTIALITY: I regard the information you share with me with the greatest respect. I will maintain confidentiality and store records of our session in a private locked location as it is a privilege of yours and is protected by state law and professional ethics in all but a few situations. These situations include: (1) if I suspect you intend to harm yourself, another person or property; (2) when I suspect a child, elder or dependent adult has been or will be abused or neglected. (3) In rare circumstances, therapists can be ordered by a judge to release information (subpoena). In all other circumstances, I will maintain confidentiality unless you give me expressed written authorization to do otherwise. All therapeutic work, including talk, movement education, body awareness, and hands-on therapy, is strictly at a professional, not a personal level. You have the right to withdraw from sessions at any time. INSURANCE: I am not a licensed therapist and do not participate with insurance companies. PAYMENT: Payment is due at the end of each session MISSED APPOINTMENT/NO SHOW/LATE CANCELLATION: If you need to cancel a session please text or email me at least 24 hours before your scheduled session. If you do not cancel, I expect you to pay for the missed session in full. This will allow me time to reschedule other clients who could benefit from the availability. True emergency situations that cannot be foreseen can be negotiated (sudden illnesses, accidents, or unpredicted loss of childcare).

Yes, I understand the above and agree to the terms of this service.