Sassafras Healing Arts Intake Form
Thank you for your interest in scheduling a session with Sassafras Healing Arts!

Please visit www.sassafrashealingarts.com to learn more about me, my training, my experience, what to expect in a bodywork session or an herbal consultation, & to read some testimonials from people who have worked with me.

Contact Information
Name *
Your answer
Pronouns (check all that apply)
Birthdate (if known)
Your answer
Phone Number *
Your answer
Email Address *
Your answer
How Were You Referred to Sassafras Healing Arts? (check all that apply) *
Required
Astrological Information (if known)
Please sure what you know - it's okay if you don't know any of you astrological information too! Just click "unsure"
Sun Sign *
Rising Sign *
Moon Sign *
More About You...
...because you are valuable & deserving of support!
Please share whatever you feel comfortable sharing about what brings you to Sassafras Healing Arts. We will have time during our session to talk in person, but it is helpful to have some information beforehand if you are willing to share. *
Your answer
How Can I Best Support You?
Please select which services you are seeking below (check all which apply): *
Required
Do you have previous experience receiving the type of care / offering / service that you are currently seeking? *
All sessions, by default, will take place at The People's Movement Center (736 East 41st Street, Minneapolis, MN 55407). Practice rooms are in the basement & require the use of stairs. If you need a wheelchair accessible option please select Svasti Yoga for our session.
When would you like the session to take place? My availability is listed below. If these times on Wednesdays don't work for you, just let me know what days & times do! I can schedule outside of my regular hours on a limited, as needed basis. If this applies to you please select 'other' & note the days & times when you ARE available. *
Required
Please briefly describe the quality of your digestion, sleep and energy levels. For example: do you experience any constipation or diarrhea regularly? Do you experience any insomnia or difficulty staying asleep? Anything else going on physically, mentally, or emotionally that troubles you?
Your answer
Are you currently taking any medications and/or utilizing any herbal supports? If so please specify the herb, supplement, and/or medication name, dose, route, & frequency.
Your answer
Do you have any allergies or chemical sensitivities? *
If you have any allergies or chemical sensitivities please share them below.
Your answer
Do you have any health conditions I should be aware of? If so please share whatever you feel comfortable sharing.
Your answer
Please list any past accidents, injuries, surgeries, and/or dental work below.
Your answer
Are you currently experiencing pain or discomfort?
If you are experiencing pain or discomfort, where is it located? Where do you feel it? When did it begin? How long has it been occurring?
Your answer
If you are interested in an herbal consultation, let me know what type of remedy you are most interested in (check all that apply).
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