BodyTalk Intake Form
Health & Well Being History-Inner Architect
Krista Hurton CBP/BAT/Agent of STHU CLI Instructor
Email address *
First and Last Name *
Phone Number *
DOB *
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Please answer all the following questions honestly and to the best of your ability.
Describe the issues for which you are seeking help. *
Past medical History ( Any Surgeries you have had) *
Any traumas/accidents physical and/or emotional *
Do you have any scars? Please describe where these are on your body. *
What daily activities are you finding difficult or are limited by? *
Have you been formally diagnosed? if so with what? *
Please check all feelings that you are/have been experiencing as of late *
Required
Please choose level of stress for each scenario *
Minimal
Moderate
Severe
None
Family Stress
*
Minimal
Moderate
Severe
None
Relationship Stress
*
Minimal
Moderate
Severe
None
Work Stress
*
Minimal
Moderate
Severe
None
Financial Stress
*
Minimal
Moderate
Severe
None
Health Stress
How is your sleep? Please check all that apply. *
Required
Do you have any allergies? please list them below. *
On a scale of 1-5, 5 being the most extreme level of pain please indicate the level of pain you are in most of the time *
Least
Most
What is your favorite color? *
What is your least favorite color? *
What is your favorite season? *
What is your least favorite season? *
Do you find that you feel cold most of the time or hot? or neither? *
Please tell me anything else you think is relevant to your sessions.
INFORMED CONSENT FOR BodyTalk and CLI SERVICES Inner Architect Krista Hurton CBP, BAT, CLI instructor BENEFITS & RISKS BodyTalk and CLI may involve both benefits and risks. Risks may include: uncomfortable feelings, the sense that things are getting worse before they get better, and in certain cases (i.e., group sessions, classes, third parties, etc.) the risk of loss of privacy. There may also be risks that are unknown at this time. Benefits may include: reduced distress, increased satisfaction in life and relationships, greater personal awareness and insight, increased mental wellness, resolutions to specific problems, physical pain and symptom reduction. You are responsible for yourself at all times. I am a facilitator that can provide information and tools to help you help yourself, but I can’t make you use the tools or information provided. APPOINTMENTS Unless otherwise specified, appointments are typically 60 minutes long. Cancellation Policy: If you cancel without 24 hours’ notice or fail to show up to an appointment, you will be charged the regular fee for the missed session. Clients will be directly responsible for missed session fees. I understand and agree to the cancellation policy. PROFESSIONAL FEES I charge $89.25 per 60-minute session unless otherwise specified. Payments may be made by credit card through my online store, cash, personal cheque, e-transfer. If a cheque bounces, I require the client to pay my bank’s service fee for bouncing the cheque ($35), in addition to the cost of the session. Payments may be made at the time of the session or as indicated on an invoice. PROFESSIONAL RECORDS I keep professional records in a secure, confidential manner. These records include information on attendance, reasons for therapy, the goals and progress in treatment, topics discussed, your medical, social, and treatment history. You own your own information and I protect it as private and confidential. You have the right to a copy of your records. CONFIDENTIALITY As a rule, I will disclose no information about you, or the fact that you are my client, without your written consent. However, there are some important exceptions to this rule. Limits to confidentiality include: • My duty to protect vulnerable persons (dependent adults and minors) • Court proceedings (files/testimony may be subpoenaed for use in court) • Imminent risk (I must report specific, immediate threats to self/others) • Records of minors (parents cannot be denied access to a minor client’s file) PARENTS & MINORS It is my policy not to provide treatment to a child under age 14 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child’s agreement, unless I feel there is a safety concern. CONTACTING ME Please feel free to connect with me via phone, e-mail, or text. *
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