Name

First Name

Last Name

Preferred Pronouns

He/him

She/her

They/them

Other

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate

YYYY

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Referred by

May I have your permission to contact this person say thank you for the referral?

Yes

What is the main reason that you are seeking somatic therapy at this time?

What current medical conditions or health issues do you have?

What is your living situation? Are you married or in a primary partnership? If so, what is your partner’s name?

Do you have any children? If so, what are their names and ages? Have you had any pregnancy loss?

What is your work (paid and/or unpaid)?

What are the most traumatic events or situations you have experienced in your life? You can briefly name them rather than describing in detail.

What has been most helpful to you in coming through these experiences?

Please list the most significant injuries, surgeries, or major illnesses you’ve had as an adult, including approximate dates:

Please list any serious injuries, surgeries, or illnesses you experienced as a child.

What do you know about your birth, the first year of your life, and the conditions for your mother during her pregnancy with you?

Please list the names of your parents, any surrogate parents, and your siblings, living or deceased. If deceased, when and how did they die? Where are you in the birth order among your siblings?

Besides parents or siblings listed above, are there other people with whom you were close who have died? When and how did they die?

Are you taking any prescription medications? If so, please give name of the drug, dosage, and the approximate date you began the medication, and for what condition it was prescribed.

What over-the-counter medications, drugs, or other remedies (either chemical or natural) do you use regularly? What, if any, nutritional supplements do you take?

Do you use recreational drugs or alcohol? How often? Do you smoke cigarettes?

What kind of exercise, if any, do you practice?

Do you have a spiritual practice?

Are there any other self-care practices you engage in?

Are you under the care of a physician or other health care practitioners? Are you presently seeing a psychotherapist, psychiatrist, or counselor? Please give names. (No contact will be made with these people without your written permission.)

Is there anything else you would like to tell me here?

BodyMind-InnerWork

BodyMind-InnerWork

Personal History Form

BodyMind-InnerWork

Personal History