DOT Center- Downtown Oakland Therapy and Couples Counseling

Somatic Music Therapy Form

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Location

CIty, State

How do you identify and what are your preferred identifiers?

This can include gender pronouns, ethnic/racial identity, age, profession, spirituality, religion, sexual orientation, etc.

What draws you to Somatic Music Therapy and what would you like to get out of it?

What is your experience with therapy and/or other healing modalities?

What kind of music do you enjoy listening to?

Please include genres, playlists, artists, or songs you've been listening to recently, and what you find yourself doing most while you are listening to music.

Have you had suicidal thoughts currently or in the past? If yes, please describe when and why you think they occurred and if you made any plans or attempts.

Have you had any incidents of self-harm currently or in the past? If yes, please describe when and why you think it occurred, how often it occurred, and what/who helped you to move through it.

Have you had any addictions to substances or unhealthy behaviors currently or in the past? If yes, please describe when and why you think it occurred, how often it occurred, and what/who helped you to move through it.

Have you ever received any diagnoses from a doctor or mental health professional? If yes, please include both physical and psychiatric diagnosis and how they have impacted your daily functioning.

Self care: What do you do to take care of your mind and body, and how often do you do it?

Support network: Who are the people and relationships that support you in your life and how do they support you?

Anything else you'd like me to know?

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