New Client Appointment Request & Intake

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Living Inspired Wellness request for initial Somatic Therapy session with trudi.knowtices.things (IG/TT).

A description of services can be found here: Available Services

(All services are virtual via Webex.)

Email *

What is your preferred (full) name and pronouns?
*

What's the best phone number to contact you?
*

Is text an acceptable method of communication? *

Yes

New client sessions are currently open on Monday, Tuesday, and Thursday at approximately 10:30 a.m., 1:30 p.m. and 3:00 p.m. (Eastern). Do those days/times work with your schedule?
*

Yes - I am available during (some/all of) those times. I'd like to go ahead and schedule an appointment.

Yes - I also want to schedule a "Resonance Consultation" to see if working together is a good fit.

No - I would like to be notified if/when earlier, later, or weekend slots become available.

New client appointments will be open up to four weeks in advance. If a session is available, you will be contacted within three weekdays with next steps. Once all slots have been filled, you may be placed on a waitlist for the next round of openings. Is this acceptable? *

Yes - I want to be added to the waitlist

No - I'm only interested in an appointment within the next four weeks.

What session type/length are you interested in scheduling?
*

Occasional 60 minutes ($222) - For a short, single somatic therapy session. Includes emailed summary and one follow-up question.

Occasional 90 minutes ($333) - For a longer, single somatic therapy session. Includes emailed summary and one follow-up question.

Recurrent 45 minutes ($150) - For clients who want to build an on-going therapeutic relationship. This option does not include summary email or follow-up question.

Please read this LIW Informed Consent and check "yes" to indicate your understanding. If you have any questions, please choose "other" and type them in.

Yes - I consent.

No - I do not consent.

Other:

Do you have a history of hospitalization for mental illness? If yes, please describe.
*

Describe your experience with "traditional" mental health services. Include modalities, dates of treatment, what worked/didn't work for you, and anything else you think might be relevant.
*

What mind/body-based therapies do you use regularly? (For example: exercise, massage, yoga, meditation, etc.) How often do you participate in them?
*

Are you interested in adding a divination element to your session?
*

Tarot/Oracle

Bibliomancy

Both

Neither

Other:

Practitioner Intention

My role as somatic therapist is to be a guide and mirror. I help you discover what your body already knows about living your best life and reflect it back to you. My intention for our time together is to help you discover what prevents you from accessing a whole version of You that's always existed, assist you in clearing those barriers, and empower you to reclaim your Self. I will be focused on you because this is your time, and I am holding that therapeutic space in support of you. I will be present and create a safe place for you to share.
Trudi @ Living Inspired Wellness

Client Intention: What are you hoping to learn about your Self as a result of this work?
*

Next Steps: Once we agree upon an appointment time, you will receive an orientation email with a link to your invoice due 24 hours prior to your session and a calendar invitation with a Webex link.
*

Sounds like a plan. I'll wait to hear from you.

This is too complicated and confusing. I've changed my mind.

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Living Inspired Wellness. Report Abuse

Forms