Questionnaire - Embrace Flow

Initial Questionnaire

I've invited you to fill in a short form to help me understand your situation better and allow our time together to be optimal. If there is anything you don't feel comfortable completing or we have already spoken about it, please leave it blank. Likewise please add anything extra you feel led to.

All information is totally confidential.

Name

Address

DOB

Mobile

How do you prefer me to contact you? Text/Phone/Email

Emergency contact and emergency number

Current Symptom(s)

Duration

Which area of your life is most affected by your situation?

What makes it better?

What makes it worse?

Have you experienced any kind of therapy / supportive modalities before?

What would you specifically like from this session(s)?

Do you have any fears or phobias?

How do you typically manage stress?

Please tell me if you have any hobbies or activities you enjoy?

Given all the demands of your life, out of 10, what is your typical stress level on average?

On average, how many hours per night do you sleep?

Please list an medical conditions, surgeries, illnesses, injuries or health concerns

Right now, are you taking any medications, either over the counter or prescription?

And finally, is there anything about your situation that would be helpful for me to know?

Name of Parent / Guardian (only required for individuals under 18yrs old)

I have read and agree to abide by the Embrace Flow declaration.

I choose to participate freely and understand that I remain responsible for my own health and wellbeing. My participation is always by choice, and I may pause to stop at any time. Together, we seek the work with the intention of do no harm.

I agree that my child for whom I am guardian may receive IEMT & Somatic Therapy

I am happy to receive newsletters, updates and other important communications

I understand that payment is required either before my session or within 24 hours after it has taken place. If I am unable to meet this, I will communicate openly to discuss alternative arrangements.

I understand that appointments are scheduled with flexibility, and I agree to give at least 24 hours’ notice if I need to cancel or reschedule. I understand that a £50 fee may apply for cancellations under 24 hours.

All information is totally confidential.

Thank you for this valuable information. All information is confidential.