Page 1 of 1

Nervous System Reset Method- Client Intake

Take your time with this. Just answer as honestly as you can.

How your body and mind respond to stressful situations/environments tells us so much about your nervous system.

First and Last Name:

Phone Number:

Email:

Date of Birth:

Place of Birth (City, State/Country) (optional)

Do you know your exact time of birth? (optional)

Why I ask for birth info: This gives me a deeper look at your core patterns—how you tend to

process stress, where things may show up in the body, and what your system naturally defaults

to. It’s completely optional, but helpful if you have it.

Your History and Goals:
Have you received massage or bodywork before?
Untitled multiple choice field
A
B

If yes, did it help?

What are you hoping to receive from this series of treatments? (Check all that apply):

What are you hoping to receive from this series of treatments? (Check all that apply):

What would feeling "better" look like for you?

What's been showing up in your body lately? What have you noticed? (select one)

What's been showing up in your body lately? What have you noticed? (select one)

What areas of your body currently hold the most tension or discomfort? (check all that apply)

What areas of your body currently hold the most tension or discomfort? (check all that apply)

How long have you been experiencing this?

Do you notice it more at certain times of day?

Are there specific activities or situations that make it worse?

How you repond to stress

In moments of stress, overwhelm, or vulnerability, most people unconsciously default to familiar behavioral patterns. Which of the following feels most like your default response?

In moments of stress, overwhelm, or vulnerability, most people unconsciously default to familiar behavioral patterns. Which of the following feels most like your default response?
A
B
C
D

Other:

When that response is active, what does your internal experience feel like?

When that response is active, what does your internal experience feel like?
A
B
C
D

Other:

When you're dealing with stress in your day-to-day life, what do you tend to do?

When you're dealing with stress in your day-to-day life, what do you tend to do?
A
B
C
D

Other:

If there is a stressful situation within one of your relationships, do you

If there is a stressful situation within one of your relationships, do you
A
B
C
D

Other:

Do your reactions ever feel bigger than the situation?

Do your reactions ever feel bigger than the situation?
A
B
C
Where these patterns originated

The stress patterns you just identified aren't random. Many (if not all) of them were learned in childhood, often as ways to feel safe.

Growing up, how did you often feel?:

Growing up, how did you often feel?:
A
B
C
D

You learned early on it was safer to:

You learned early on it was safer to:
A
B
C
D

When someone upsets you now, you:

When someone upsets you now, you:
A
B
C
D

Anything else you'd like me to know

If there's anything you haven't had a chance to share yet, you can include it here:

Have you experienced any significant stress, injuries, or live events that you feel may still be affecting your body? (optional)

Is there anything that feels important for me to understand before we work together?

Would you be open to receiving my free What Is My Body Telling Me guide?

Would you be open to receiving my free What Is My Body Telling Me guide?

Today's date: