Are you ready?

Take the first step towards more self knowledge, emotional freedom, and physical relief. After filling out the form below, a page will appear to choose a time to schedule a call.

Most questions below are optional and not mandatory, though taking the time to fill them out can greatly benefit our clarity, and in extent, your desired outcomes.

First calls are an opportunity to answer your additional questions about the work, express your needs, and understand the parts of your nervous system, history, and body that may want to be addressed before touch is possible.

Name

First Name

Last Name

Pronouns

Disclosing your pronouns is always your choice.

Email

What have you tried already? What other practices and support are you currently receiving?

Do you have a support system that can resource you in this work? As an Emotional Release Therapy practioner in training, I’m an individual part of a broader potential holistic support system (ex: other professionals, friends, animals, safe enough places?)

I understand that Emotional Release Therapy is not psychotherapy or medical treatment.

Yes

Confidentiality will be held unless consent is given. I will not record our sessions unless consent is given. I recognize and hold that this work is vulnerable for both client and coach.

Yes

I will abstain from consuming alcohol or drugs during, or prior to, treatment.

Yes

Either I, or Santi, may choose to terminate my session at any time.

Yes

I am solely responsible for my health and safety and I agree to not hold the practitioner responsible for any loss, injuries, or illness that may occur as a result of my participation in this bodywork session. I understand that this work is hands on and may result in superficial bruising, tenderness, or short term muscle soreness. I agree to not hold the practitioner responsible for any exacerbation of undiscovered injury.

Yes

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

What do you want from this work together? What questions are you asking?

Your intention(s) and goals can help guide this work. Please consider and state your deepest intention(s) regarding your relationship to your self, your emotions, your body, and your wellbeing. Write down any goals that you would like to accomplish during our work together. Keep in mind that although you may come in with an intention or goal, your body may wish to clear other parts first.

What is your social location?

Social location refers to the identities you carry in the world that may impact your access to social privilege and power, such as but not limited to racialization and culture, age, ability/disability, sexuality, and gender. The purpose of sharing this information is solely for me to better understand and meet your needs, and is never a requirement.

What would happen if you don't do this work?

Is there anything else that you'd like me to know?