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Name

First Name

Last Name

Phone

Request Date

YYYY

Have you had any previous experience with Somatic Release, Body Electronics, or another body-mind therapy?

Do you have any acknowledged addictions (drugs, alcohol, sex, relationship, food, etc.)?

Do you now or have you previously taken prescription drugs or chemical treatments?

Have you ever had, now or in the past any of the following conditions or experiences?

Heart or high blood pressure Seizures Strokes Surgery Anesthesia Given birth Been revived after a physical death Had a fracture or a major physical trauma Car accident Diagnosed or hospitalized with a mental illness Thoughts of suicide Under the care of a doctor for a chronic illness Under the care of a therapist

Please describe your spiritual background and training

Do you have support in an emotional crisis?

What do you see as the primary issues or traumas you are dealing with?

What would you like to achieve from this session?

Rates & Policies

ZOOM SESSIONS: I am currently offering Zoom sessions to individuals worldwide. These last for 60 minutes and the fee is $175.

IN PERSON SESSIONS: Available in Albion, CA starting 2026.

LOWER RATE FEES: When possible, I offer a limited sliding scale.

Payments: Venmo: @nicosutra or Paypal: nicosutra@gmail.com.

CANCELLATION POLICY: Please note, that I require a 48 hour cancellation notice. I understand that unexpected problems come up in our busy lives and would much prefer not to charge for missed sessions, but I need to make open hours available to clients, who are waiting for appointments, and protect my own time as well. However, if it is possible to reschedule you the same week, I will waive this policy.

CONFIDENTIALITY POLICY: All information shared during sessions remains strictly confidential.

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Rates & Policies