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2023 Client Intake Form - Melanie Joye LMT
Please fill out the intake form to be added to online booking system.
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Email
*
Your email
First & Last Name
*
Your answer
Cell Phone
Number
will be added to your online booking profile for text reminders
*
Your answer
Address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Emergency Contact Name & Number
*
Your answer
Referral Contact
*
Your answer
Occupation
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Your answer
Injuries: surgeries, accidents, broken bones, sprains, wounds
Common contraindications for bodywork include communicable diseases, certain allergies, fever, rashes, blood clots, long flights day of session. If you are pregnant, please get clearance from your doctor.
*
Your answer
Health Care Team:
other practitioners, therapist, PT, chiropractic, medical, etc
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Your answer
Health Care Support:
meds, supplements
*
Your answer
Mobility:
daily exercise or movement
*
Your answer
Allergies or sensitivities:
scents, peanuts, animals, oil/lotion, etc
*
Your answer
Pain Points:
what are your goals or pain points for your sessions?
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Your answer
What sessions are you interested in?
*
The Emergence Process (neuroemotional processing & reprogramming)
Bodywork 60m (structural integration/fascia bodywork)
Bodywork 90m (structural integration/fascia bodywork)
Combo TEP + Bodywork
Structural Integration 10 Series (aka Rolfing - 10 progressive sessions)
Animal Neuro Muscular Release or Emergence Process for Pets
Required
Anything else you would like me to know?
Your answer
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