Client Intake Form — Somatic By Anna

About You

Basic contact information and how to address you.

First Name *

Last Name

Email Address *

Phone / WhatsApp

Age

Location / Time Zone

How did you find me?

What Brings You Here

Take your time with this section. The more honest you are, the better I can prepare.

In your own words, what is going on for you right now? What made you reach out? What are you carrying? No need to filter or explain it well — raw is fine.

What do you most want to change, release, or understand? What would feel like success after working together?

How long have you been feeling this way?

Patterns & Nervous System

Check anything that resonates. You don't have to experience these all the time — even occasionally counts.

Describe a specific pattern you most want to change A loop you keep finding yourself in — a relationship dynamic, a behaviour under stress, an emotional response that doesn't serve you

Healing & Therapy History

This helps me understand what you've already explored — and what hasn't been enough.

Have you worked with a therapist, psychologist, or counsellor?

Yes — I'm currently in therapy Yes — I've done therapy in the past No

What has helped most in your healing journey so far? Even if it was temporary, partial, or something you found by accident

What has NOT worked — and why do you think that is?

Health & Medications

Somatic work is safe for most people, but some health conditions and medications are important context for how I support you. Everything here is confidential.

Are you currently taking any medications?

Yes No

If yes — please list them Particularly psychiatric medications, antidepressants, mood stabilisers, or anything affecting the nervous system. You can be vague (e.g. "antidepressant") if you prefer.

Any diagnosed physical or mental health conditions? PTSD, CPTSD, anxiety disorder, depression, chronic pain, fibromyalgia, autoimmune conditions, heart conditions, epilepsy — or anything else relevant

Any history of trauma you'd like me to be aware of? You don't need to share details. Even a general note ("childhood trauma", "recent loss", "relationship trauma") helps me calibrate.

Preferences & Beliefs

This helps me understand how you experience healing and what approaches feel most aligned for you.

Which modalities are you most drawn to or curious about?

Somatic / body-based therapy Breathwork Energy healing EFT / tapping Hypnotherapy Yoga / movement Psychology / pattern work Meditation / stillness practices

How comfortable are you with physical touch during sessions? Most of my online work doesn't involve touch — but for in-person sessions, this is important to know

Very comfortable — touch is welcome as a grounding tool Somewhat comfortable — I'm open to it with clear communication I'd prefer no physical touch at this stage Unsure — let's discuss

What do you believe in? What shapes your worldview? Religion, spirituality, science, a combination — there's no wrong answer. I work with all frameworks and adapt to yours.

How does your body typically hold stress? Where do you feel it physically? (jaw, chest, gut, throat, shoulders, nowhere, everywhere...)

Readiness & Context

Is there anything in your life right now that might make deep work harder? Big life stressors, instability, transitions — I don't need details, but knowing the terrain helps me pace us

Emergency contact (name and phone number)

Is there anything else you'd like me to know before we begin? Anything you didn't know where to put, a fear about the process, a hope, a question — all welcome here