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
1) Name *
2) Pronouns (check all that apply)
3) Birthdate, Birth Place, + Birth Time (If Known - Required for Astrology Readings)
4) Phone Number *
5) Email Address *
6) 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"
7) Sun Sign *
8) Rising Sign *
9) Moon Sign *
More About You...
...because you are valuable & deserving of support!
10) 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. *
How Can I Best Support You?
11) Please select which services you are seeking below. Check all which apply. Note that each modality requires an individual (separate) session. Sessions may be scheduled back to back as time allows for multiple treatments per virtual visit. *
Required
12) Do you have previous experience receiving the type of care / offering / service that you are currently seeking or will this be your first time? *
13) When are you available for your session? My availability varies greatly these days, so just let me know what works for you! All sessions to take place via Zoom or another virtual platform arranged for ahead of time. *
14) 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?
15) Are you currently taking any medications and/or utilizing any herbal supports? If so please specify the specific herbs (list out all individual herbs in blended formulas), supplement, and/or medication names + dose, route, + frequency. This helps us to make the best use of the time we have together if I have this info ahead of time.
16) Do you have any allergies or chemical sensitivities?
Clear selection
17) If you have any allergies or chemical sensitivities please share them below.
18) Do you have any health conditions I should be aware of? If so please share whatever you feel comfortable sharing.
19) Please list any past accidents, injuries, surgeries, and/or dental work below.
20) Are you currently experiencing pain or discomfort?
Clear selection
21) 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?
22) If you are willing, please share what you know of your ancestry and/or ancestral homelands. Whenever possible I will try to connect you with plants that illicit ancestral rememberings.
23) If you are interested in an herbal consultation, let me know what type of herbal supports you are most interested in (check all that apply). They run approximately $20 - $30 sliding scale fee, depending on size
24) If you are interested in an herbal consultation, what is your budget for the herbal supports?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy