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Pediatric/Minor Intake Form 
All information provided on this form is kept confidential. The information provided will best help the therapist tailor your child's bodywork sessions according to their history and current situation. 
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*If someone referred you, please let me know so I can thank them!
Name of Parent/Guardian *
Address  *
Email of parent/guardian *
Cell Number (for appointment reminders, etc.) *
Name of child/client *
Child's date of birth *
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Please describe your concerns regarding your child and primary reasons for seeking out craniosacral therapy/bodywork?  *
Religious or spiritual affiliation (if any)
Please list any diagnosis your child has received: *
Please list any prescription medications your child takes: *
Please list any major accidents/broken bones/ surgeries:

 *
Was your child delivered full term? *
If premature, please describe the circumstance:
Please indicate the type of birth your child had *
Please indicate the position of birth your child had *
Did your child's birth require assistance through use of forceps or vacuum? *
Please note any other birth events such as fetal distress, umbilical cord concerns, birth injuries, or anything else about your child's birth experience that is notable.
Was your child breast or bottle fed?
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Does/did your child use a pacifier or thumb?
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Did/does your child have any late development milestones? Please indicate below: *
Has your child suffered any emotional or physical trauma that you are aware of? *
Mark any therapies your child has received in the past or is currently receiving? 
Does your child currently have a counselor/therapist who can help your child process anything that may surface during a bodywork session? (if the child is of age)

 *
Cancellation Policy
If you need to cancel, please contact the office directly to cancel your appointment.  Please cancel your appointment, if needed, before the morning of your appointment day so that your appointment can be filled. Appointments that are not cancelled are considered “no-shows”. These no-show appointments will be billed the full rate of the scheduled session.
Consent & Release Form

I voluntarily give my full consent to Stefanie May (LMBT #22392) to perform the physical therapy modalities she is currently licensed and certified to perform (massage therapy, dynamic body balancing, craniosacral therapy, myofascial unwinding) on my child. I understand that I am consenting to a function of ministry to my child's body, soul, and spirit for their highest good and integration as a triune being. 


I acknowledge that there is some risk inherent in the use of the therapy equipment and therapy procedures. I agree to assume such risk and indemnify and hold Stefanie May and TriBalance Integrative Bodywork harmless from any and all losses and claims for any injuries or other damages occurring to my child or my belongings. I also do not hold her responsible for any further or additional care that my child may need in the future. 


I attest that I am here voluntarily and I acknowledge that I am free to terminate my child's participation at any time and for any reason. I understand that I must take full responsibility for any and all consequences for terminating this service prematurely. I also accept full responsibility for any choices I make that may be detrimental or harmful to me after a session with Stefanie May. 


I take full responsibility for my child's life, health and wellbeing, now and in the days to come. 

Digital Signature agreeing to cancellation policy, consent, and release form above (required for hands on bodywork therapy). Please sign your name below: *
Please list names of any providers you would like Stefanie to be able to discuss your bodywork therapy with:
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