New Client Intake Form
Please come to the session wearing comfortable, loose or stretchy clothing like what you would wear to the gym or yoga. A 50% non-refundable deposit is required to book & can be paid via Venmo to @ConsentCoalition
Aleah will respond with her availability within 48 hours! 
Email *
Your Full Name *
Your Phone Number *
Your Email *
Location You're booking for *
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Which session are you booking? *
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Medical Info: Are you currently pregnant? If so, how far along are you? *
Medical Info: Do you suffer from chronic pain? If so, please explain below.
What makes your chronic pain feel better? What makes it feel worse?
Medical Info: Have you had any orthopedic injuries (broken bones)? If so, please describe.
Medical Info: Please indicate any of the following conditions that apply to you: (Thai massage is not recommended if you have any of the following conditions)
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SESSION AGREEMENT:   I  will inform my practitioner of any changes in my physical health.   If i fail to do so I cannot hold my practitioner responsible for any incurring injuries as a result.   I understand that a practitioner cannot diagnose any illness, disease, or any other mental, physical or emotional disorder.   I am responsible for consulting a qualified physician for any ailments outside of my bodywork practitioners scope of practice.   I understand that my session today is for therapeutic purposes only and strictly professional.   If the client makes any sexual advancement, physical or verbal, the practitioner has the right to end the session, and client will be responsible for paying the full amount of the session.  I understand that if i arrive late, my session will end at the original scheduled time as not to affect following clients' appointments and client is still responsible to pay the full price.  I agree to give a 24-hour notice for a scheduled session that I cannot keep.   I am aware that I may be charged the full fee of any missed sessions that I do not give 24-hours notice to cancel or reschedule. Please type your name and date below to agree + sign.
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CLIENT BILL OF RIGHTS:  1) Aleah Graham, unlicensed Thai Bodywork, Cupping & Reiki Practitioner,  (2) Certified in Thai Bodywork levels 1 & 2 & Usui Reiki attuned "The state of New York has not adopted any educational and training standards for certified, unlicensed health care practitioners. This statement of credentials is for information purposes only. Under NY law, an unlicensed health care practitioner may not provide a medical diagnosis. If a client desires a diagnosis from a licensed physician, chiropractor, or acupuncture practitioner, or services from a physician, chiropractor, nurse, osteopath, physical therapist, dietician, nutritionist, acupuncture practitioner, athletic trainer, or any other type of health care provider, the client may seek such services at any time".   (3) Aleah is self-employed in her own office-space, all of her clients have the right to file a complaint with her at any time; please email all complaints to sound.spiral.healing@gmail.com.   (4) Aleah's prices start at $165/hour depending on the service. She offers add-ons to all her sessions that range in Price. Aleah accepts cash, paypal, venmo, and all major credit & debit cards. Aleah is insured by the Great American Alliance Insurance company. She cannot accept Medicare, medical assistance, or general assistance medical care at this time. Aleah offers specials & package deals that allow clients to receive services at a discounted rate.   (5) The client has a right to reasonable notice of changes in services or pricing. (24 hours notice).   (6) Aleah utilizes 4 different positions to access the clients sen-lines & wind-gates. She uses suction cups to break up stagnation and improve circulation in the body. She also utilizes visualization techniques & symbols to impart healing reiki energy throughout the seven chakras.   (7) Clients have a right to complete- and current information concerning the practitioner's assessment and recommended service that is to be provided, including the expected duration of the service to be provided.   (8) Aleah’s clients may expect to be free from verbal, physical, or sexual abuse during their sessions and free from discrimination based on race, gender, sexual orientation, age, religion, etc.   (9) All client records and transactions with the practitioner are confidential, unless release of these records is authorized in writing by the client, or otherwise provided by law.   (10) A client has a right to be allowed access to records and written information from records in accordance with the provisions of this chapter.   (11) All client’s have the right to choose freely among available practitioners and to change practitioners after services have begun, within the limits of health insurance, medical assistance, or other health programs.   (12) All clients may refuse services or treatment, unless otherwise provided by law.(13) All clients may assert the client's rights without retaliation.  By signing below, I acknowledge my rights & responsibilities.  
PLEASE TYPE YOUR NAME AND DATE TO ACCEPT + SIGN
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