Name: Somatic Therapy for Stress and Trauma
Address: Chorlton, Greater Manchester, UK

Full Name *

Telephone Contact *

Address *

Date of Birth *

Your Next Of Kin: Name | Relationship | Contact Number* *

Your GP Name and Address

Email *

Are you currently experiencing thoughts of harming yourself or feeling unsafe?

Details of any medications and name and profession of the prescriber *

N/A if none

you yourself to

Medical History and Any Diagnosis *

N/A if none

What brings you to this consultation, what would you like to to take away?

Checkboxes *

I agree: This consultation is not a substitute for medical care, psychotherapy, or mental health treatment provided by a qualified professional. Somatic work and nervous system education can support awareness and positive change, however this session is educational in nature. Any choices, actions, or changes I make remain my personal and legal responsibility.

Consultation Intake