New Client Assessment
Please take the time to fill out the assessment form prior to your session.
* Required
Email address
*
Your email
Have you booked your session already? I know it might seem like a silly question, however, I only check assessments once I see a new client booking on the calander.
*
Yes
No, but I will make sure to schedule online at Tranquilitywhen I'm done with this assessment.
Required
What is today's date?
*
MM
/
DD
/
YYYY
Name (First and Last)
*
Your answer
Phone Number
*
Your answer
How did you hear out about Tranquility Rising
*
Your answer
How often do you receive body work (Thai Yoga Therapy, Massage, etc).
*
Your answer
Assessment Questions
These questions allow me to give you a more accurate assessment at the end of your session. Thai Yoga Therapy is not a massage it is so much more. I aim to create an entire wellbeing plan to help you achieve the best possible outcome from your sessions. Please take a few moments to give as much information so I can create your custom assessment.
Please describe your lifestyle. This includes occupational and recreational. (i.e. sitting for long periods of times at a desk, physical labor, leisure actives, etc.)
*
Your answer
Describe your eating habits.
*
Your answer
List your medical history current and past: surgeries, medical diagnosis, injuries.
*
Your answer
I want to be able to hold space for you in the best way I can. We know that emotional or physical traumas can be held in the tissue of the body please briefly mention anything that you may have experienced. You do not need to go into detail if you choose not to. Examples PTSD, Sexual Assault, Domestic Violence, etc.
*
Your answer
Are you experiencing depression, anxiety, anger, or any other emotional disruption that you feel is hindering you day to day. If so, briefly list how it is effecting you and how you have tried to balance it out.
*
Your answer
Why are you seeking this type of therapy, what are your goals from your session.
*
Your answer
Do you have anything you wish to share with me that has not been asked?
Your answer
At the end of the session you have the option for me to go over the meridian lines of the body and elemental questions related to the meridian blocks that I found during your session. Please choose one of the following:
*
Yes, I am interested in this part of the assessment.
No, I am looking just to receive bodywork.
If you chose YES for the last question please block 2 hours off for your appointment. If NO your session will be 90 Minutes.
Please arrive on time for your appointment and early if you need to change into different clothes.
Thank You For Completing Your Assessment
Remember to wear comfortable workout clothing to your session, remove all jewelry (women no underwire bras).
Send me a copy of my responses.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Forms
