Somatic healing intake form

I’m so glad you’re here, and I look forward to supporting you on your journey of healing and self discovery.

Please take a few moments to answer the following questions. This information will give me a better idea of who you are, what you’re looking for and your current mental and physical state. This helps me support you in the best way possible by creating a treatment unique to your personality, strengths and areas for growth.

Any information you share on this form or during a session is protected and confidential.

Contact Information

Name

First Name

Last Name

Gender Identity

Pronouns

Birth Date

YYYY

Phone

(###)

###

####

Self Reflection

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 is your biggest challenge or obstacle?

How do you think somatic coaching could help you with this?

Describe what your life might look like if you successfully managed these challenges.

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?

How do you typically deal with stress?

What do you find helps you when you're struggling?

Which of the following appeal to you?

Select as many as you'd like.

Brainstorming strategies together

Support, encouragement and validation

Direct feedback and tough love

Unleashing your potential and gaining insight into who you are

Creating vision of what you can accomplish

Accountability and check-ins

Exploring and managing blocks to your success

Suggesting or designing action steps

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, 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

Kari Burke is a somatic behavioral coach. Kari trained in Cognitive Behavioral Coaching with Oxford Psychologists, has degrees in Psychology and Dance Performance/Choreography, studied Dance Therapy and Laban/Bartenieff Movement Analysis and is certified in Motivational Interviewing. 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, Skype 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.

Name

First Name

Last Name

Date

YYYY

Parent or Guardian Name (if under 18)

First Name

Last Name

Somatic healing intake form

I’m so glad you’re here, and I look forward to supporting you on your journey of healing and self discovery.

You belong here. ♡