Intake & Consent Form

First Name*

Last Name*

Basic Information

Full Name

Date of Birth with Birth Time

Address

Phone

Emergency Contact (Name, Relationship, Phone)

Family Doctor

Occupation / Workplace

Additional Context for Therapy

Have you had counselling or therapy before?

NoYesNo

What was helpful or unhelpful?

Is there anything about your history or identity that feels important for me to understand as we begin?

Are there particular approaches, environments, or therapist qualities that help you feel safe?

Health & Lifestyle

Current medications or supplements

Other health professionals you see

Relevant medical conditions

Sleep (hours + quality)

Movement/exercise (type + frequency)

Time outdoors each week

Habits or patterns that feel unsupportive right now

SRT may include breath-work, body awareness, bilateral sound, aromatherapy, and optional light touch.

Somatic Regulation Therapy (SRT)

Have you tried somatic or mindfulness practices before?

How comfortable do you feel noticing sensations or emotions in your body?

Any sensitivities to sound, scent, or touch?

Is there anything about somatic work that feels activating, exciting, or concerning?

Support & Safety

Do you feel safe in your current living environment?

Are you navigating crisis, recent trauma (last 30 days), or thoughts of harming yourself?

Who or what supports you (people, practices, community, spirituality)?

Are there any cultural, spiritual, or personal frameworks that shape how you understand healing?

Practical Details

Do you have a private space for virtual sessions (if applicable)?

Are you open to gentle between-session practices (grounding, noticing, journaling)?

Touch Consent (Optional for SRT)

Touch preference

Boundaries or preferences

(Optional)

Anything Else You'd Like Me to Know

Anything else you'd like me to know

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

Your information is kept by the clinic for as long as its professional order requires, and your account data for as long as your account is active. A deleted record is permanently purged 45 days after its deletion. Details in our privacy policy.

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