Client Intake Form

Please Fill In the form below

Name

First Name

Last Name

Phone

Subject

Describe your muscle pain. Where is it located? Is it chronic? How long have you had it?

Please list any accidents, injuries, major illnesses, or surgeries you’ve experienced as far back as you can remember.

Please list any treatments you’ve already sought. Which ones have been beneficial?

Are you under the care of a physician? If so, what is their diagnosis of your pain condition?

Are you currently on any medication? If so, what?

Date of Birth

What is your profession?

What are your hobbies or interests? What do you do to relax?

Are there any activities or hobbies that you can no longer do because of your pain or limited movement? If so, please explain.

What is your goal for this/these session(s)?

Please use the space below to share any other concerns, details, or information not addressed above.

What is your average daily energy?

What is your average daily stress?

How did you hear about Denise Balyoz Somatics?

Please check the boxes below.

I agree & have read to the terms & conditions listed.

I would like to be on Denise's mailing list for updates, discounts & more (Your privacy is always respected!)

Terms & Conditions

CANCELLATION POLICY
Online private sessions or video consultations are eligible for a full refund minus a 10% cancellation fee if canceling more than 24 hours in advance. If you purchased a discounted session package, the sessions you have already received will be treated as full price sessions and you will be refunded the difference. Reimbursement is not available in the event of a no-show or a cancellation/reschedule request less than 24 hours in advance.

CONSENT
I hereby consent to voluntarily participate in Somatic Movement with Denise Balyoz. I understand that Somatic Movement is a safe, gentle approach to addressing muscle tension and pain and that it is not a high-risk, strenuous, or physically demanding activity. I understand that Clinical Somatic Education is not medical in nature and does not claim to treat, diagnose or prescribe any disease. I understand that Clinical Somatic Education is movement education, the goal of which is to improve sensory motor awareness, muscle function, physical comfort and freedom of movement. I understand that all Somatic Movements and movement explorations are undertaken voluntarily by myself and that if any movement is uncomfortable, I will discontinue it and communicate directly with the trainer.

RELEASE OF LIABILITY
In consideration of my participation in Somatic Movement with Denise Balyoz, I do hereby, for myself, my heirs, executors, administrators, assigns, or anyone else who might claim on my behalf, waive, release, and forever discharge Denise Balyoz Somatics and its officers, agents, employees, representatives, and executors, and all others from any and all responsibilities or liabilities from any injuries or damages to myself, including injury or damage caused by negligence or gross negligence of Denise Balyoz Somatics, its officers, agents, employees, representatives and successors, and all others. I fully understand I may injure myself as a result of voluntarily participating in these movement programs and it is still my desire to participate as herein indicated.

PHYSICAL CONDITION
I hereby represent that I am in good physical condition and do not suffer from any condition, illness or injury that could be adversely affected by Somatic Movement. I am not relying on Denise Balyoz to evaluate this information for medical purposes, and I will rely solely on my physician or other medical professional to advise me concerning such matters. If my physical condition or medication change, I will inform the trainer immediately.

CONFIDENTIALITY
I have been informed that the information obtained in this Somatic Movement session will be treated as privileged and confidential and will not be released to others unless my consent is provided or in case of a medical emergency.