Welcome to Sama Integrative Wellness!
A holistic approach to therapy is a transformative practice that integrates the body, mind, and spirit. If I know more about you, it will facilitate our process together as we co-create your experience.
In addition to the required fields, please fill out only what you feel comfortable sharing.
What is your address?
Fill this in if only if you intend to have any sessions at your location.
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Birthdate or Age
{"type":"text","name":"birthdate","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please enter your birthdate or age.","placeholder":""}
Emergency Contact Name
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Emergency Contact Relationship
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Emergency Contact Phone Number
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How did you find out about Sama Integrative Wellness?
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What is your occupation?
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Would you like to join the Sama Integrative Wellness email list?
{"type":"radio","name":"joinemaillist","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose \"yes\" or \"no\".","options":"Yes\nNo"}
What are your reasons for seeking this type of modality(-ies)?
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Have you been hospitalized in the past three years?
{"type":"radio","name":"joinemaillist2","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose \"yes\" or \"no\".","options":"Yes\nNo"}
{"type":"textarea","name":"__generic4","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":"If so, what was/were the reason/reasons?"}
Have you done yoga before?
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{"type":"textarea","name":"__generic5","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":"If you have done yoga before, what styles? Please list them here."}
How healthy do you feel your diet is?
{"type":"radio","name":"diet","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one answer.","options":"Very Good\nGood\nFair\nNot So Good\nVery Bad\nPrefer Not to Answer"}
How stressful do you feel your life is?
{"type":"radio","name":"stresslevel","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one answer.","options":"No Stress\nMild Stress\nModerate Stress\nMuch Stress\nExtreme Stress\nPrefer Not to Answer"}
What is (are) the main causes of stress in your life?
{"type":"textarea","name":"stresscause","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":"What stresses you out?"}
How do you deal with stress?
{"type":"textarea","name":"destressby","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share something, even if the answer is: I'm not sure. ","height":80,"placeholder":"What destresses you?"}
How many hours of sleep do you typically get a night?
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Do you generally feel well rested?
{"type":"radio","name":"wellrested","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please choose \"yes\" or \"no\".","options":"Yes\nNo"}
How many cups of water do you typically drink in a day?
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Do you smoke?
{"type":"radio","name":"smoke","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose \"yes\" or \"no\".","options":"Yes\nNo"}
Are you currently pregnant?
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Are you currently consulting a/an (please check all that apply)?:
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other:
{"type":"textarea","name":"AdditionalCare_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please share the amount of cups of water you drink a day in a numerical value. ","height":80,"placeholder":"Please list any other professionals you are currently seeing."}
Please check any that apply to you:
{"type":"checkbox","name":"difficulties","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Addiction to Drugs/Alcohol\nAnxiety\nArthritis\nAsthma (Please review additional question below.)\nBack Pain\nBipolar Disorder\nBruise Easily\nCancer\nChronic Pain\nCommunicable Disease (Including, but not limited to shingles, hepatitis, HIV.)\nDepression\nDiabetes (Please review additional question below.)\nEar Issues\nEpilepsy\nEye Issues/Glaucoma\nFibromyalgia\nHeadaches\nHearing Loss\nHeart Trouble\nHigh Blood Pressure\nHypoglycemia\nInsomnia\nIntestinal Disorders\nJoint Swelling\nLow Blood Pressure\nMigraines\nOsteoporosis\nPace Maker Implant\nSeizures\nSinus Condition\nSleep Difficulties\nStroke\nSurgery in the Past Five Years (Please explain more below.)\nThyroid Issues\nWear Contact Lenses\nWhiplash"}
Other:
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If you have asthma, do you use an inhaler?
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If you have diabetes, do you use insulin?
{"type":"radio","name":"__generic19","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the answers.","options":"Yes\nNo\nNot Applicable"}
If you have had a surgery in the past five please explain more here:
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What does optimal health mean to you?
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What gives you a sense of meaning and purpose in life?
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What are your creative outlets?
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What aspects of your life give you the most joy and pleasure?
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Is there any additional information you would like to share?
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Thank you for taking the time to fill out this form.
I look forward to connecting with you!
