Wave Somatics - New Client Info Form

Name:

First Name

Last Name

Preferred Gender Pronouns:

Your Age:

Email:

Phone:

Country

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Emergency Contact (Name, Phone, Relationship):

Occupation and interests/hobbies:

Previous Alexander Technique work, if any:

Previous Somatic Experiencing work, if any:

Relevant Medical History:

List any surgeries you've had, and at what ages:

Please list any physical/mental/emotional traumas or accidents you are hoping to address through somatic work. Only share briefly what you are comfortable sharing here. We will discuss details in person, so there's no need to go into great depth here.

Are you currently taking any medications/supplements? If yes, please explain.

Please list your past or current psychotherapy experiences (how long, what type, with whom):

Allergies:

What are the main goals you are hoping to achieve through this work?

Any other relevant information, special needs, or requests:

How did you hear about Wave Somatics?

There are inherent confidentiality risks in submitting personal information electronically. While safeguards are in place to ensure your privacy, you should not electronically submit this form if you are concerned about any breaches of privacy that might inadvertently occur. In that case, please notify Wave Somatics via email or phone so that a New Client Info form may be emailed to you in order to print out and mail or submit in-person.