Registration for Drop In Somatic Release

Purpose

A somatic break session is a brief, body-centered intervention designed to promote relaxation, self-regulation, and awareness of physical sensations. These sessions may include guided breathing, movement, grounding techniques, or other mindfulness-based practices.

Name

First and last name

Address

Number, street, city, zip, state

Date of birth

Email address

Phone number

Sex

Female Male Intersex Prefer not to say

Gender identity

Female Male Non-binary Transgender women Transgender man Prefer not to say Other

Emergency contact

Please provide name, phone number, email, and relationship to individual

Would you like to receive emails about future training opportunities?

Yes No

I understand that: • A somatic break session is not a substitute for psychotherapy or medical treatment. • Participation is voluntary, and I may stop the session at any time. • While generally safe, somatic practices may bring up unexpected emotions or physical sensations. • I agree to communicate any discomfort and understand I can modify or decline any activity. • The therapist is not liable for any adverse reactions resulting from the session. By signing below, I acknowledge that I have read, understand, and consent to participate in the somatic break session.

Agree

1. Confidentiality:

Information shared in this group is considered confidential and will be treated in accordance with applicable privacy laws. While group leaders are bound by professional ethics and HIPAA (if applicable), please be aware that confidentiality cannot be guaranteed among group participants.

2. Notice of Privacy Practices:

By participating, you acknowledge that you have been offered access to Birmingham Therapy Services’ Notice of Privacy Practices, which outlines how your information may be used or disclosed. A full copy is available upon request.

3. Good Faith Estimate:

Under the No Surprises Act, you are entitled to a Good Faith Estimate for services. This drop-in group is a one-time, self-pay service with a total cost of $50. No ongoing services or billing are implied. A full GFE is available upon request.

4. Payment:

I understand that a one-time payment of $50 is required to attend the group. Payment is non-refundable unless the group is canceled by the facilitator.

I have read and agree to the confidentiality, privacy, and payment terms outlined above.

Yes

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Registration for Drop In Somatic Release

Birmingham Therapy Services, LLC