Client Intake Form

Your Music & Healing Journey

Please fill out the form below before your first session or class so that we may better cater the experience to you and your needs.

This form takes approximately 2 minutes to complete. Feel free to hit "play" on the music below to accompany your form-filling self-care and reflection time! (This song is exactly 2:12 minutes long.)
CLIENT INTAKE FORM

Part 1: My Experience

Name Email Preferred pronouns How I heard about Somatic Singing My comfort level with singing: My comfort level with meditation: My comfort level with breathwork:
Are you familiar with any of the following? (check all that apply)
Accupressure
Ayurveda
Breathwork
Breath Anatomy & Physiology
Body Talk
Chakras
Energy work
Fascia
Gymnastique Sensorielle
Guided Meditation
Gut Biome
Gut-Brain Axis (GBA)
Iyengar Yoga
Nervous System Physiology
Pranayama
Polarity work
Reiki
Somatic Therapy
Speech Level Singing
Traditional Chinese Medicine (TCM)
Vocal Warmups
Submit

This form takes approximately 2 minutes to complete. Feel free to hit "play" on the music below to accompany your form-filling self-care and reflection time! (This song is exactly 2:06 minutes long.)
CLIENT INTAKE FORM

Part 2: My Health

Please let us know if you've experienced any of the following health conditions, as they can store energy in the throat, lungs, and gut, which all affect the voice.

Name Preferred pronouns
Relevant Health Issues (check all that apply)
Anxiety (social or otherwise)
Arthritis (neck or shoulders)
Asthma or Respiratory issues
Autoimune diseases
Autism spectrum
Bipolar disorder
Cancer (thyroid or lung)
Cancer (other)
Chest pain
Constipation, IBS, or Abdominal pain
Covid-19 (lasting cough)
Covid-19 (no lasting symptoms)
Cystic Fibrosis
Deafness
Depression
Diphtheria
Easting disorders (Anorexia or Bulimia)
Gastroenteritis or frequent vomiting
Gastroesophageal Reflux (acid reflux)
Gut issues or bloating
Heart Conditions
HIV or AIDS
High Blood Pressure
Hyper/Hypothyroidism
Laryngeal Papillomatosis
Nerve disorders
Multiple Sclerosis
Pain (neck, shoulders, jaw)
Parkinson's disease
Scoliosis
Tuberculosis
Whooping Cough
other
Health issues not listed: What I'm feeling and healing Submit

This form takes approximately 2 minutes to complete. Feel free to hit "play" on the music below to accompany your form-filling self-care and reflection time! (This song is exactly 2:05 minutes long.)
CLIENT INTAKE FORM

Part 3: My Energy

Name
Chakras I'm interested in working with:
🔴 Root
🟠 Sacral
🟡 Solar-Plexus
🟢 Heart
💠 Throat
🔵 Third-Eye
🟣 Crown
all of the above 🌈
not sure yet 💭
My Ayurvedic Dosha My TCM Temperature My TCM Element My Astrological Sun Sign Submit

This form (optional) takes approximately 1-2 minutes to complete. Feel free to hit "play" on the music below to accompany your form-filling time! (This song is exactly 1:40 minutes long.)
CLIENT INTAKE FORM

Questions? Comments?

Name Email Questions? Comments Submit

This form takes approximately 4 minutes to complete. Feel free to hit "play" on the music below to accompany your form-filling self-care and reflection time! (This song is exactly 4:05 minutes long.)