Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

###

####

Emergency Contact Information *

First Name

Last Name

Phone

(###)

###

####

Light Touch Consent *

Light Touch Consent - Some of the practices during our sessions may involve light touch. This can help with grounding, supporting your movement, or encouraging connection. Touch will always be offered with care and respect for your comfort. If you ever feel uncomfortable with touch or any part of the session, please let me know at any time. Your comfort and safety are my priority.

Yes

No

Confidentiality: *

Your privacy is important to me. All information shared in our sessions will remain confidential, except in the case of harm to yourself or others. Do you agree to this confidentiality policy?

Yes

No

Consent for Participation: *

I agree to participate in the sessions offered, understanding that they are not a replacement for traditional therapy. I understand that the work is holistic and may involve physical movement, breathwork, and other practices.

Yes

No