Name

First Name

Last Name

Email

Are there any body based practices (movement, breathwork, chanting, journaling, etc.) that currently support you or have in the past?

Please list them here.

Are there any body based practices or movements that are inaccessible or unsupportive that you would like to avoid during our time together?

If yes, please list them here.

Are there any triggers (words, motions, sounds, etc.) or stressful themes that may compromise your sense of safety during our session?

If yes, please advise here. There is no need to relive a stressful or triggering experience right now or during our time together so you do not need to share specifics here. For example: don't ask me to close my eyes

What is your hope for our session together?

Is there anything else that you would like me to know?

Jillian Parkhurst

Jillian Parkhurst

Somatic Safety Intake Form

Jillian Parkhurst