New Client Consultation Form

Name

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Country

E-mail*

Phone Number*

PrefixPhone Number

Date of Birth*

Date

Occupation

Emergency Contact Name and Phone Number *

Please check the box if you have had any of the following medical conditions*

Please check the box if you have any of the following:*

Please explain any conditions marked above and list any other conditions not listed here (please go into detail below, when did it start, treatment received, is it ongoing?

Current Medications:*

Stress Levels at Home*

HighMediumLow

Are you currently working outside the home (occupation please if yes)?

Stress Levels at Work*

HighMediumLown/a

Exercise/Hobbies? *

How would you describe your current emotional state? *

Any known allergies/sensitivities (eg: latex, nuts, essential oils)? If so, which? *

What is your daily water intake (glasses)

How many hours of sleep do you receive each night?

What is your sleeping position?

What do you hope to accomplish with this massage? (i.e. relaxation, decrease back pain, increase flexibility, emotional support, all of the above...)*

Are you currently in pain or experiencing any discomfort? If so, please briefly explain and name those areas below. If not, just answer N/A*

What makes it BETTER? (Body positions, certain movements/activities, better at certain times of the day...etc... Including medications)

What makes it WORSE? (Certain movements/activities, body positions, worse at certain times of day... etc)

Briefly Describe the onset of how pain/symptoms began, or how injury occurred

What specific areas would you like for me to stay away from?

Is there any other information you would like to make your therapist aware of? If yes, please give details:

Reservation & Cancellation Policy for all current and future appointments: In the event of cancellations received less than 24 hours prior to appointment a cancellation fee equal to the reserved service booking will incur. No Shows will be charged 100%. Suspected Covid-19 and other medical related issues are exceptions to this rule, but please do let me know asap*

I understand the reservation and cancellation policies and consent to be billed the full amount if I fail to give the required notice.

I occasionally contact clients to follow up on a session and I also send booking confirmation and a reminder via email / SMS. I occasionally send emails regarding updates, special offers etc. You may unsubscribe from these emails at any time. Please confirm you give your permission to:*

Contact you about appointment and relevant follow up.Send occasional emails with news, special offers etc.

YOUR BODYWORK SESSION

Sessions may involve touch, but it is not a requirement and it will always/only be with consent. I understand that at any time I may withdraw my consent and treatment will be stopped. Clients are encouraged to continuously communicate boundary requirements with the therapist.

I understand that sexual advances of any kind will not be tolerated. This includes any insinuation, joke, gesture, conversation, or request and this will result in immediate termination of my session and a refusal of any and all services in the future.

Bodywork is provided for stress reduction, relaxation, relief from muscular tension, improvement of circulation and energy flow, as well as a means to support the nervous system's regulation while encouranging the client's awareness and self regualtion skills. This might include a certain amount of participation from the client during the session.

Alejandra Hajduk is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness, and nothing said by her in the course of the session(s) given should be considered as such.

It is expected that if the client experiences pain or discomfort during the session, that they will immediately inform the therapist so that pressure/strokes can be adjusted to an appropiate level of comfort.

REGARDING EMOTIONAL EXPERIENCE

At times a client may experience a surge or release of emotion during a session (e.g., crying, laughter, sadness, anger, muscle twitching, appearance of memories or images, etc.). This is normal. The client and practitioner work together so that the experience stays within the client’s window of tolerance and are supportive of the client’s particular purposes for the session.

SESSION LENGTH

The length of somatic therapy sessions varies on the preferences and needs of the client. I offer 75, and 105 and 120 minute sessions. 105 minute sessions are recommended for first time clients. Each session includes time at the beginning to discuss what the client wishes to address and sufficient time at the end to allow the client to process the events of the session and/or to feel grounded and ready to leave the studio.

LATE START

If the client arrives late to an appointment, the session will end at the originally scheduled time so that the practitioner can stay on schedule. If the practitioner starts a session late, she will make the time up at the end of the session when possible and if not, the session fee will be reduced proportionate to the amount of time lost. If the client is late more than 15 minutes to a session, they will be asked to reschedule and will be charged 100% of the session price.

CHILD POLICY

Children are not permitted to accompany clients to appointments. If a client brings a child to an appointment, they will be asked to reschedule and a no show cancellation fee will apply (see Cancellation Policy).

ILLNESS OR CONTAGIOUS DISEASE

If a client arrives sick or otherwise contagious to an appointment, they will be asked to reschedule the appointment

COMMUNICATION

Communication between sessions is limited to information related to scheduling appointment, appointment reminders and payment related issues.

Signature*

Thank you for taking the time to complete this form - I look forward to seeing you soon. Alejandra Hajduk LMT

Alejandra Hajduk LMT Therapeutic Bodywork Intake Form

General Health Information: