First Name *

Last Name *

What is your current occupation and how long have you been doing it? *

What’s happening in your life right now that has you potentially considering receiving somatic therapy? And ultimately, what’s your goal? (please be as detailed as possible) *

Do you have any specific medical complications, physical limitations, chronic health issues? *

Do you have a history of trauma (Please note, with any potentially triggering trauma experiences - you never need to share personal, sensitive details with me - its enough to simply note the broad strokes without exposing anything you would prefer to keep private. A simple yes/no answer is enough.)  *

What would be your ultimate goals for treatment? Ex) to feel less physical pain, to feel deeply connected with myself, to remove burdens of past negative experiences, etc. *

Your email address for the calendar invite? *

What is your phone # as a backup for the video call? *

Which of the following best describes your ability to invest in yourself? *

I have the funds, or can get access to funds so I am able to invest myself.

I do not have any access to funds and am living paycheck to paycheck with no access to credit.

The Somatic Bodywork Intensives are held just outside of Asheville, NC - if this is the right therapeutic solution to your current challenges, are you willing to travel to receive treatment in person? *

Yes

If you decide that the Somatic Bodywork Intensive is the right solution to your current challenges, what date would you choose to start treatment? *

On the following page you will be able to schedule a call with our team... Will you 100% be able to make the time you choose? We do not reschedule no shows. *

Yes - I will stay 100% committed to the time I choose.

Maybe - I'm not sure if I'm serious.

Were you referred directly by anyone? How did you find me? *