Customer Intake Form
The information collected in this form is to provide you with the best experience during your session. Your information will remain confidential and not shared with any third parties.

Why do I need to fill this out?

There are many reasons why practitioners ask their clients questions such as the ones you are about to answer. One of the reasons is as a practitioner we need to be aware of any pertinent medical questions that may affect your session or be encountered in your session (ie. If a client has Diabetes or medical history that may result in client having a medical emergency, your practitioner would be then able to convey any needed information to paramedics if the situation is extreme. It's also important to know if the client has any areas of concern so that other arrangements can be made, such as ability to lie down on front or back, or if extra pillows and support are needed.)

Another reason is that the service you are requesting is not a guessing game. While energy will travel to where it needs to go, your practitioner can better prepare if she knows why you are seeking treatment and what your areas of concern are.

It is also important that you understand what the session is about and that you consent to the treatment. As a practitioner, I am bound by a code of ethics and am accountable to uphold those ethics.

What if I don't feel comfortable writing everything down?

Totally fine. We can discuss any issues when you arrive. This form helps speed up the intake process but we can spend a few minutes going over it in person once you arrive. If you can though, please fill out as much as you can beforehand. Thank you!

Name
Your answer
Date
MM
/
DD
/
YYYY
Emergency Contact & Ph#
Your answer
Recent Surgeries or Medical Issues
Your answer
Are you currently on any medications
Your answer
Do you or have you ever had:
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