Clinical Somatics Session Intake Form

  • All information will be kept strictly confidential. We will discuss your conditions in more detail in person, but filling out this form will allow us to be more efficient and effective during your session.
  • List all physical activities or hobbies that you do on a regular basis. For example: computer work, weightlifting, gardening, etc.
  • List or briefly describe all pain and other conditions that you are experiencing.
  • Please list all injuries, surgeries, major illnesses, and medications that you are currently taking.