The Sovereign Inquiry

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Mindful Marlyss

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A short intake form to begin working together intentionally.

First name*

Last name*

Phone*

Email*

Emergency contact info:*

Do you know you dominant Dosha?

Multi choice

Vata

Pitta

Kapha

To create a safe and supportive space, are there any areas of your body that you would like me to be mindful of? Please know that you have complete control over any physical touch or exploration of sensations in our work together.*

Please note any areas of the body where you are experiencing emotional and or physical discomfort?*

Topics to be addressed?*

Topics to be avoided?*

Please list anything you have been through that you consider traumatic? *

Have you experienced sexual trauma?

yes

prefer not to say

Are you comfortable closing your eyes while moving?

yes

Are you comfortable closing your eyes while meditating?

yes

Please describe your personal practice in terms of style and frequency of yoga, meditation and breathwork.

On a scale of 1-10 how much do you believe the following statement, 10 being a "hell yes" and 1 being "no way"? "Everything is working out in my best interest"

How would you describe your current relationship with your body

How comfortable are you with exploring bodily sensations in a therapeutic setting?

Are there any specific physical sensations or areas of tension you experience

Are there any specific emotions that you find challenging to process?

How do you typically cope with stress or difficult emotions?*

What are your availability and scheduling preferences?*

Mindful marlyss

marlyssmatthews@gmail.com

San Jose, CA, USA

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