Intake Form: Maui Somatics New Intake Form PhoneThis field is for validation purposes and should be left unchanged. Maui Somatics LLC Lisa Cary Client Intake Form Name(Required) First Last Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone(Required)Cell Phone(Required)Doctors nameCurrent medications / dosages (including over the counter):I was referred to this office byDescribe the issue, symptom or problem you would like help with__(Required)On a scale of 1-10 with 10 being the strongest, how strongly would you rate this issue?What specific problem you would like assistance with? Please describe:What does this issue or problem keep you from doingWhat is this issue doing FOR you? What is it offering you?What, if any, health problems to you have?What is the number one thing you want out of our work together? What is the outcome you would want?What do you see as being the biggest obstacles in your way in terms of creating your vision of the life you would most like to live?What activities/hobbies do you enjoy?Where is there conflict in your life? What are you resisting?What do you believe is unavailable to you? (Health, Abundance, Safety, Purpose, Relationship, etc. What is there not enough of in your life?Briefly describe your spiritual beliefs or sources of peace, love or joy? What spiritual resources do you have, if any? By what name do you call your spiritual supports?Are you willing to be actively involved in your healing process by doing recommended movements or practices at home?_____If no, please commentFrom this list below check any areas that concern or apply to you Achieving Goals Addictions Anorexia Anxiety Bulimia Childhood Problems Compulsive Behavior Confidence Death Depression Drinking From this list below check any areas that concern or apply to you Drugs Eating Problems Exercise Fears Fertility Food / Diet Gambling Guilt Hair Growth Hearing Illness From this list below check any areas that concern or apply to you Isolation Mobility Money Issues Motivation Pain Control Panic Attacks Performance Anxiety Phobias Pot Procrastination Public Speaking Fear From this list below check any areas that concern or apply to you Relationships Relaxation Self Esteem Sexual Problems Sight/Vision Sleep Problems Smoking Stress Weight Problems Other If other, please specify belowAnything else you want me to know?Session Type Preferred Online on Zoom In Person All the sessions except for bodywork are available by ZOOM.Consent Join the email list for information on Somatics Classes
