Compassionate Practices Client Waiver

Client Intake Form

All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent.

Full Name *

First Name Middle Name (Optional) Last Name

Date *

Month Day Year

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Birth Date

Month Day Year

Phone Number *

E-mail *

Emergency Contact *

Phone Number *

HEALTH HISTORY

For your safety, Massage Therapists & Yoga Teachers must be aware of any history regarding any of the following conditions. Therapeutic massage & yoga may impact these conditions and your health. Please take a moment to fill in any of the conditions that may apply and make appropriate notes.

Medications

Allergies, Skin Sensitivities and Infectious Conditions

Cardiovascular

Surgeries, Injuries, Accidents

List any areas of concern, pain or discomfort you would like to address in your massage or yoga session

If applicable, please let me know if you are pregnant and how far along you are.

Please list any other injuries, illnesses, or information relevant to your session you would like to include.

If you are coming to massage or yoga to support trauma healing, are you currently working a mental health professional?

POLICIES

Your session is reserved especially for you! If you wish to cancel or reschedule your session, kindly give as much notice as possible. Cancellations within 24 hours of your appointment time will be charged 50% of the value of the service.

Payment is due at the time of service. I accept Venmo: @Natalie-McGreal, Zelle: nataliemcgrealyoga@gmail.com, cash or check.

Client services and chart information are confidential. Written authorization is required from you to release any information.

Please silence your cell phone for optimal relaxation.

You will have a consultation with Natalie to discuss your session.

For massage: Should the session require, after your massage therapist has left the room, you may disrobe to your comfort level.

For massage: You will be draped appropriately at all times.

I understand that Natalie or I may end the session at any time for any reason.

Inappropriate behavior will not be tolerated and may be prosecuted.

Natalie McGreal is an SE™ Practitioner in Training. Natalie weaves and integrates Somatic Experiencing® and Somatic Education techniques into classes and sessions.

The Somatic Experiencing® method is a body-oriented approach to the healing of trauma and other stress disorders. It is the life’s work of Dr. Peter A. Levine, resulting from his multidisciplinary study of stress physiology, psychology, ethology, biology, neuroscience, indigenous healing practices, and medical biophysics, together with over 45 years of successful clinical application.

As with all other techniques used, Somatic Experiencing® and Somatic Education are entirely optional.

CLIENT AGREEMENT

I understand that my session is for the purpose of stress reduction, relief from muscular tension, general relaxation and improvement of circulation.

I understand that at any time I feel discomfort or pain, I will inform Natalie so they may adjust accordingly.

I also understand that Natalie McGreal does not diagnose any illness, disease, physical or mental disorders; does not prescribe medical treatments or pharmaceuticals, nor do they perform any spinal manipulations.

Massage therapy and yoga are not a substitute for medical treatment or diagnosis, and it is recommended that I see a physician for physical ailments.

I have stated all my known medical conditions and understand it is my responsibility to keep Natalie updated on any changes in my health so that they may make any appropriate adjustments to our sessions.

I agree that Natalie McGreal, and all their agents, contractors, employees, representatives, executors, insurers, and all others acting on their behalf as well as any buildings, and/or property will not be held liable for any and all claims or liabilites for injuries or damages to my person and/or property that may arise during or as a result of this or any future sessions.

By my electronic signature below, I agree to the massage and yoga policies and client agreement above.

For Outdoor Yoga:

Addendum: Coronavirus/COVID-19
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. Natalie McGreal has put in place preventive measures to reduce the spread of COVID-19.

However Natalie McGreal cannot guarantee that you will not become infected with COVID-19.

ASSUMPTION OF RISK: By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury, illness, damage, loss, claim, liability, or expense, of any kind, that I may incur.

WAIVER OF LIABILITY: I hereby release, covenant not to sue, discharge, and hold harmless Natalie McGreal from all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating to COVID-19.

Signature *

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