Please fill out this form to the best of your abilities and note that we will review it in full, in person, during our first session. Any information you choose to share will not be sent via email—and will only be stored in our system for privacy consideration. Still, please only share here what you feel comfortable sharing online.

For new clients with jewels, doing business as Unstruck Somatics, LLC.

Name *

Email Address *

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Consent & Boundaries

Please read and check each box: *I understand that Somatic Intuitive Healing (SIH) is a trauma-informed holistic approach that supports emotional, relational, and nervous system healing through techniques such as Biodynamic Craniosacral Therapy, Polarity Therapy, Somatic Experiencing, Diamond Approach, and Movement/Yoga Therapy.Touch During Sessions: I understand that SIH may involve physical or energetic touch, applied while I am fully clothed, to facilitate somatic learning and deepen self-awareness. My participation in any touch is always by my choice, and I can withdraw my consent at any time, during any part of a session.Not Medical Diagnosis or Treatment: I understand that the SIH practitioner does not diagnose illness, disease, or any other physical or mental disorder, and does not prescribe medical treatment or pharmaceuticals. I am advised to consult with a licensed healthcare professional for any medical concerns.Not Medical Care or Therapy: I understand that SIH is not a substitute for medical examinations, diagnosis, or treatment, nor is it a substitute for licensed therapy or counseling. It is recommended that I see a physician for any physical ailment and a licensed therapist for any mental or emotional health concerns.Not Massage: I understand that SIH is not massage.Emotional/Somatic Risks: I acknowledge that bodywork may bring up emotions or trauma. I take responsibility for my well-being. I understand it's my responsibility to communicate with my practitioner if anything feels uncomfortable, in any way.Confidentiality: I acknowledge that while my practitioner is not bound by HIPAA or other regulatory boards governing licensed healthcare professionals, any information I choose to share will be kept private unless there is a disclosure of harm to self or others, as required by ethical and legal considerations.Payment Policy: I am responsible for all charges for all services provided by my practitioner and will pay balances before our session, or on the day I receive it.

Health & Accessibility

Please skip any questions you'd prefer to share in person.

Please share any relevant medical conditions, injuries, or surgeries:0 / 180

Please share any trauma history you’d like me to be aware of:0 / 180

Please share any access needs or requests (e.g., scent-free, mobility accommodations):0 / 180

Other healing modalities you’ve tried:0 / 180

Healing Intentions

What brings you to SIH? What would support look/feel like for you?0 / 180

How do you prefer to be supported in moments of distress?0 / 180

Liability Waiver

Consent *

I voluntarily assume all risks related to SIH sessions and release Unstruck Somatics, LLC from claims arising from participation. I understand that the practitioner is not liable for my physical/emotional state before, during, or after sessions.

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