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Syrene Therapies & Consulting
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Intake form
Help us serve you better
Name
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Email address
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Phone number
What brings you to syrene therapies & consulting today?
Please select at least one option.
Neurological Touch & Mobility Therapy
Dance-Based Movement Therapy
Corporate Wellness
Brunch Therapy Events
Customized Healing Pathways
Other (please specify)
Where in your body are you currently holding tension?
Please select at least one option.
Neck
Lower Back
Hips
Jaw
Everywhere
I’m Not Sure
How do you currently manage stress or regulate your emotions?
Please select at least one option.
Exercise
Suppression
I cry/sleep
I don’t
I try breathing/movement
What pace of transformation feels right for you?
Select
Gentle daily nudges
Weekly focus
Deep immersion/reset
What is your current relationship to movement?
Please select at least one option.
I move often
I avoid it
I’m in pain when I move
I crave it but don’t know how
What are you open to exploring?
Please select at least one option.
Touch therapy
Dance/movement
Energy reset
I’m not sure
Do you have any specific goals or areas of focus for your healing journey?
Have you previously participated in any wellness programs? if so, please describe.
Do you have any medical conditions or injuries we should be aware of?
How did you hear about syrene therapies & consulting?
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Social Media
Friend/Family Referral
Website
Event
Additional questions or comments
Appointment Preferred Date/Time
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