Trauma Touch Therapy Form | Spiritual Warrior

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Trauma Touch Therapy Intake Form

Please complete the form below after booking your appointment. Our system is safe and secure. Your privacy is of the utmost importance. For more information, visit our privacy policy.

Today's Date

First Name

Last Name

Email Address

Address

Phone

May a message be left? *

Yes

Birthday

Age

Physician Name

Therapist Name

Emergency Contact

Physician Phone

Therapist Phone

Emergency Phone

Relationship to you

Why are you seeking Trauma Touch Therapy?

Have you ever had any exeperience with body work? If so, please explain how you felt about it.

Have you had any experience with psychotherapy and counseling?

What is your intention for these sessions?

Current medical conditions, medications, treatment or substance abuse.

Abuse History (Type: Physical, Emotional, Sexual, Elder, Home, Workplace, Social).

Abuse History (Mark al that apply)

Physical

Emotional

Sexual

Elder

Degree of Abuse (Choose one)

Past

Present

Both

FOR YOUR INFORMATION:
As a Trauma Touch Therapist, I am not qualified to make any diagnosis or prescribe any treatments. All recommendations are to be viewed as suggestions. All sessions are confidential. Please see my Notice of Privacy Practices. All sessions are strictly non-sexual in nature. Client remains fully clothed during sessions.

CLIENT RESPONSIBILITY AGREEMENT:
I agree that I am responsible for my well-being while participating in TTT (TRAUMA TOUCH THERAPY).

I agree to be responsible for my participation in, and creation of, this therapy.

I agree to take responsibility for my truth, my feelings and needs, and whatever issues arise for
me, and ask for support when necessary.

I am willing to have learning transformation happen in ways that are totally loving and kind to me and everyone else.

I declare that the information I’ve provided is accurate & complete.

I acknowledge I have read and agree to the terms, policies and procedures of this office.

Your Signature

Date

Name Printed

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