Registration for SE

Registration form - Somatic Therapy

Submit this form for details about Somatic Therapy sessions

Name

Gender

Age (in years)

Phone

Country

Health conditions (ailments, etc.)

Intentions / Goals

Consent

I invite you to my Somatic Experiencing® and Qigong healing practice. I am a certified Somatic Experiencing® Practitioner certified by the US-based Somatic Experiencing Trauma Institute (SETI). I am also a certified Tai Chi and Qigong Master and will be integrating Tai Chi and Qigong techniques with Somatic Experiencing® therapy in my trauma healing sessions.

I do not diagnose, prescribe, or treat any physical or mental ailments. A Somatic Experiencing® session may provide you relief from your traumatic stress symptoms, increase your resilience and ability to self-regulate, and improve your physical, mental, emotional and spiritual condition. However, similar to any stress reduction treatment, there are no guarantees that you will achieve your goals, though many people have acknowledged the positive changes this therapy has enabled in their lives.

Terms and Conditions

- Somatic Experiencing® may result in unintended negative side effects, such as sleep disturbances, vivid dreams, a shift in symptoms, distress or anxiety, unpleasant memories, or unfamiliar and uncomfortable feelings and/or body sensations. Such reactions are not uncommon and are often a sign of healing. If you are experiencing any of these symptoms or changes, you are encouraged to share them with me.

- As part of an in-person Somatic Experiencing® session, I may offer you touch support. I will seek your informed consent before initiating touch. If you are not comfortable with touch, the session will not include any form of physical contact.

- Somatic Experiencing® therapy for trauma resolution is conducted over multiple sessions. However, you may terminate your sessions at any time. At termination, a closure session is generally recommended.

- Everything you share with me during a Somatic Experiencing® session will remain confidential. If you are a minor, I am required to share important information regarding your emotional health with your parents.

- A Somatic Experiencing® session is usually conducted seated in a chair. However, based on your personal comfort, I may invite you to lie on a therapy table.

- Your Somatic Experiencing® session will begin at the time of the scheduled appointment and generally runs for 50 minutes. You are in complete control of the session and may end the session at any point.

- In the event you are unable to attend a scheduled appointment, please provide a minimum advance notice of cancellation of 24 hours. If failed to do so, there will be no refunds.

Acknowledgment

Submission of this form indicates your understanding and acceptance of the terms of this consent form.

YOUR CART

Registration form - Somatic Therapy

Consent

Terms and Conditions

Acknowledgment

Thank you!