Name
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First Name
Last Name
Email
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Phone number(s)
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Date of birth
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DD
YYYY
What draws you to do this work in particular?
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Are there any negative patterns, symptoms or circumstances in your life or way of being that you'd like to change?
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What would you like to call more of into your way of being and living?
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----------- Grief/sadness ----------
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"I often feel grief/sadness."
"I find it easy to express grief/sadness."
"It's easy for me to cry when I need to."
Do you find yourself often overwhelmed by it, or numbed to it? How do you feel when you see strong expressions of this in others? What were your parents’ or carers’ attitudes to it when you were growing up?
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---------- Anger/Boundaries -----------
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"I often feel angry."
"I find it easy to express anger."
"I find it easy to hold my own boundaries."
Do you find yourself often overwhelmed by it, or numbed to it? How do you feel when you see strong expressions of this in others? What were your parents’ or carers’ attitudes to it when you were growing up?
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----------- Joy ----------
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"I often feel joyful."
"I often feel excitement and exuberance."
"I feel comfortable expressing excitment and joy in the presence of others."
Do you find yourself often overwhelmed by it, or numbed to it? How do you feel when you see strong expressions of this in others? What were your parents’ or carers’ attitudes to it when you were growing up?
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---------- Sexuality ----------
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"I feel I have a lot of sexual energy."
"I find it easy to express my sexuality and feel comfortable with myself as a sexual being."
"I'm comfortable with other people of my gender expressing their sexuality."
Do you find yourself often overwhelmed by it, or numbed to it? How do you feel when you see strong expressions of this in others? What were your parents’ or carers’ attitudes to it when you were growing up?
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Do you have any history of or current major mental health problems?
Such as major depression, self harm, or panic attacks? Have you ever felt suicidal in the past or currently? Have you ever had a psychotic episode or been sectioned under the Mental Health Act?
Do you have any history of major trauma? You may feel to give details or just a sense of the type, such as ‘medical’ or ‘sexual’.
This includes any frightening or overwhelming experience which continued to affect you long term. or anything which might be seen as major trauma even if you are unaware of its effects on you.
Are you currently taking any medication?
Have you participated in any healing or somatic (body-based) therapies in the past? Are you engaged in any specific spiritual traditions/ways/practices, or have you been in the past?
Give brief details.
Any other information or life circumstances which you feel it may be good to share?
Self responsibility: Finally, please read the exciting legal garb below...
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I, the client, hereby swear that I have been wholly truthful and honest about my health history and current conditions. I am choosing to participate in this session by my own free will. I understand that this work can bring difficult feelings and emotions to the surface. I take full responsibility for myself, and my healing process, and I will not sue or take court action against Zazie Zeff or Sacred Somatics, for any injury, illness or health problems occurring during or after this session and/or any other activities with Zazie Zeff. I release and waive all claims against Zazie Zeff and Sacred Somatics from any and all liability, claims, or damages of any kind whatsoever. This agreement shall serve as a release and assumption of risk for me, my heirs, executors, administrators, and assigns and all members of my family. I understand that by returning this form and ticking the box below I am agreeing to the above and am thereby allowed to participate in sessions with Sacred Somatics.
