Benefits of Somatic Experiencing Touch Work | Light of Awareness Somatic Psychotherapy

First & Last Name*

Your Pronouns (she/her, he/him, they/them, etc.)

Birthdate *

Your email*

Phone Number*

City/State of residence

Have you had trauma occur in an ongoing nature throughout your childhood?

Yes, and I have a primary therapist who supports me with this, and I'm interested in SE Touch Work

Yes, but I do not yet have a primary therapist to support me with this, so we are not a fit at this time for SE Touch Work

Yes, but I have had therapy in the past and these issues are not actively affecting my daily life

I have had one or more isolated traumas during childhood, but not of an ongoing nature

No

Do you have a personality disorder (Ex: Bipolar, Borderline Personality Disorder) or Major Depression?

Yes, and I have a primary therapist who supports me with this, and I'm interested in SE Touch Work

Yes, but I do not yet have a primary therapist to support me with this, so we are not a fit at this time for SE Touch Work

Yes, but I have had therapy in the past and know how to effectively manage my mental health symptoms and these issues are not actively affecting my daily life

No

Please describe any somatic symptoms or give me the "headline" of any traumatic incidents you are seeking support with, and/or add any other areas of focus you'd like to work on in therapy:

What issues are you wanting help with? What is your desired outcome of therapy?*

What issues/symptoms/circumstances are arising that have you seeking support now?*

When are you able to meet?

Mondays (In Person in Portland) between 10:30am-5:00pm (only SE® Touch Work Option)

I can't meet on Mondays, so we are not the right fit at this time

I do not offer support between sessions. Do you have enough support in your life for that boundary to work for you?

Yes

No, I need a therapist who can support me between sessions and in crisis situations

I am interested in:*

Weekly ongoing Somatic Experiencing® Touch Work

Twice a month Somatic Experiencing® Touch Work

Short term or as-needed Somatic Experiencing® Touch Work (3-8 sessions)

For SE® Touch Work, indicate you understand we would have 1-3 preliminary sessions to assess if touch work is a fit for you at this time:

Yes, I understand and consent

No, I am not interested in SE ® Touch Work

What is your experience with somatic work?*

Beginner: It's hard for me to know what I'm feeling and to sense how those feelings show up in my body

Intermediate: I'm good at noticing my body's signals, feelings, and needs, but want help going deeper

Advanced: I have had training and practice in sensing how my emotions live in my body and following my body's impulses and signals to find healing, expression, regulation, and empowerment

How will you be paying?*

Pacific Source [not OHP plan]

Open Card or Fee For Service [FFS] (through Oregon Health Plan)

Regence Blue Cross Blue Shield

Aetna

Out of pocket ($165-$225 sliding scale)

I have out of network benefits on my insurance plan

If you plan to use insurance, I can check your benefits and let you know if I can provide you with services and if there will be any cost to you. Please let me know the following (if you're comfortable sharing): The name of the insurance company that handles your Behavioral/Mental Health Care (often located on your insurance card):

Your insurance ID number, and group number if you have one:

Your insurance health plan customer service phone number on the back of your card

If you are an Open Card/Fee for Service [FFS] member (a type of OHP), please give me your social security number so I can check your benefits. If you'd prefer not to enter it, call and leave it on my confidential voicemail at: 619-289-7604

Have you been in mental health therapy before? If so, what modality [ex: Cognitive Behavioral Therapy] and if so, how was it for you? *

Have you ever been diagnosed with a mental health condition? If so, please briefly describe:*

Have you ever been hospitalized for mental health concerns? If so, please briefly describe:*

Have you ever been arrested or incarcerated? If so, please briefly describe:*

Do you take any mental health prescription medication? If so, please describe what you take, for which diagnosis/symptoms you take it, and for how long, and whether it is effective/supportive:

New Client Questionnaire

* indicates a required field

Thank you so much for taking the time to fill this out!

I will get back to you soon, and if it seems like we may be a fit, the next step will be a free 15-30 minute virtual consultation. I may not have availability to schedule our first session until October, 2025.

If we move forward with working together, we will do 3 preliminary sessions and then check back in to see if we are a good fit to continue.

**If form wont submit, go back and ensure you filled out all the required fields indicated with a * next to the question, and that you chose two options in the questions that indicate you must do that.**

If you are interested in starting Somatic Experiencing® Touch Work, please fill out the below questionnaire as the first step!

IMPORTANT LIMITATIONS OF WHAT I OFFER: If you have Complex Trauma (when acute trauma has been pervasive, throughout the lifespan in different ways, especially throughout all of childhood), or diagnoses that benefit from specialized support (such as a personality disorders or Major Depression), I require you to be working with a primary therapist to process past issues and to support you in the present to engage in Somatic Experiencing® Touch Work with me. If you have engaged in therapeutic and/or psychiatric support in the past and these issues are effectively managed and not actively affecting your daily life, please fill out my new client questionnaire, and let's have a consultation to see if Somatic Experiencing® Touch Work is right for you. If you are supported by a primary therapist and would like to add Somatic Experiencing® Touch Work to augment your therapy, you can fill out my new client questionnaire, and then we can have a video consult to see if it makes sense to move forward. Then, with your consent, I can consult with your therapist, to hear their perspective on how Somatic Experiencing® Touch Work may fit into your support system.

New Clients: I will have several openings starting Oct. 1, 2025 will offer consults throughout September. Please fill out my new client questionnaire to schedule a consult!

These questions are intended to assess if this work and myself as the practitioner would be beneficial and the right fit for you at this time, so thank you for answering honestly. I want you to find the right support!

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