Intake Form Thank you for taking the time to complete this intake form. Everything shared will be held in confidentiality. Name * First Name Last Name Email * Phone * (###) ### #### What is your primary language, and if applicable, your secondary language? * Please share what calls you to this work. What are you feeling called to tend in your life? * Is there anything you are longing for? Do you have previous experience with therapeutic coaching, therapy, or psychotherapy? * Do you have experience with somatic therapies? If so, what kind, and how did those practices feel for you? What are some resources in your life? Resources can be held as things that offer a sense of ease, joy, calmness, etc. to your body and mind. These can be people, animals, nature, places, activities, etc. More simply. what helps you feel good? * Do you have a spiritual practice? This can include meditation, ritual, earth connection, or anything that brings *you* a sense of interconnetion. Is there anything about your identity (race, ethnicity, sex, gender, religion, etc.) that would feel helpful to share? Please share your pronouns. If you are comfortable sharing, please list any prescriptions, medications, or herbs you currently take, or have taken in the last six months. Is there anything else that would feel helpful to share? General Agreements * Please check the following boxes to confirm. I understand that Natalie is not a doctor or medical therapist, and therefore cannot diagnose, treat, prescribe, or offer medical advice. Sessions with Natalie are not intended to replace my relationship with my doctor or medical therapist. I will share if anything significant changes with my mental or physical health - especially if it affects our work together. I commit not to sue Natalie Shapiro or Bridging the Soul for any and all liabilities, claims, and demands arising from our work together. I am aware that sessions are offered on a scale of $150 - $225 per 60-75 minutes. I commit to this rate, or our agreed upon rate, and I will communicate if I have particular needs around pricing in order to make our sessions accessible for me. I agree to the 24-hour cancellation policy. If I cancel within the 24 hours our scheduled session, I will owe payment for that session. Sacred Agreements: * Please check the following boxes to confirm. I understand working with Natalie is a collaborative process, and just as much as she has responsibility to hold a safe and supportive container, I am also aware that my growth, learning,, etc. depend on my willingness to offer attention and devotion to my journey. I am a sovereign being, and even as I step into receiving support from Natalie, I have complete ownership and choice of my life. I will do my best to let Natalie know if I have particular needs around safety and wellness in our shared container. As I enter into this work, I understand I might meet challenging places, and I intend to be kind with myself and stay the course. Please type your name as your signature below in the following format: /s/ name * Date MM DD YYYY Thank you for for your time and care!In gratitude. If you have any question, please feel free to send a note.In love. CONTACT Contact 2 Name * First Name Last Name Email * Message * Thank you!
