CONFIDENTIAL CLIENT INTAKE

Holistic Natural Structural Therapy:

Your job is to heal. My job is to assist, and to provide you with the tools and techniques for healing.

My name is Chahna and I am a certified Biofeedback Technician and Holistic Structural Therapist. I specialize in biofeedback-enhanced pain & posture correction by integrating a number of advanced and holistic techniques and modalities.

WHAT IS NATURAL THERAPY?

In contrast with conventional therapies, which seek to impose the will of a therapist on the body of a client, Holistic Structural Therapy seeks to assist the body in restoring normal balance and function on its own terms. Holistic Structural Therapy is respectful and honoring to the body and to nature.

By identifying the unique needs of each individual being and by communicating and working with the body's inner intelligence, the Holistic Structural Therapist provides support and assistance while the body rids itself of "stuckness", freeing trapped energy and restoring free and open movement. The self-healing coach empowers you to do all of this yourself at home.

HOLISTIC NATURAL STRUCTURAL THERAPY IS RIGHT FOR YOU IF:
- you have pain, restricted range of motion, posture problems, a general sense of un-wellness OR you are interested in prevention and maintenance for body, mind, and spirit
- you accept 100% responsibility for your health, your wellbeing, and your life circumstances
- your preference is to leave drugs and surgery for the very last resort
- you are willing and able to follow simple home-care instructions between appointments
- you understand and agree that no one can impose healing on you without your participation and a commitment to yourself
BENEFITS OF HOLISTIC NATURAL STRUCTURAL THERAPY
- heal faster
- feel better
- stand taller
- breathe deeper
- increase mobility
- better moods and increased happiness
PLEASE READ!!

THE REMAINDER OF THIS PAGE CONTAINS IMPORTANT INSTRUCTIONS TO PREPARE FOR YOUR FIRST APPOINTMENT.

My intake forms are very detailed and comprehensive - it is likely to take some time for you to complete. Please fill out these forms when you are well rested and able to read each question carefully, and answer each question completely.

Please contact me at (307) 640-2496 or relax@transformationswellness.net if you have any questions, or any problems with this form.

Following is a checklist to follow in the days and hours leading up to your appointment time. I recommend that you print this page as a reminder:
- Schedule your first appointment here: https://www.transformationswellness.net/schedule/
- Fill out all online intake forms - there are 5 parts (click "Next" at the bottom of this page, then click "Submit" at the bottom of the last page.)
- Wear or bring modest and loose or stretchy briefs to wear during posture assessment and treatment (I can provide tube tops for women who don't have appropriate bras - sports bras are ideal. Everyone is on their own for bottoms)
- IMPORTANT: Be sure that you have NOT taken any pain-relieving substances, including alcohol and all prescription and over-the-counter pain relievers, for at least 8 hours prior to your appointments, as these substances interfere with the natural healing process. Try to refrain from taking these substances for an additional 72 hours after treatment, if possible. (In fact, the fewer synthetic chemical you have in your body at all times, the better to facilitate your healing. One of the primary objectives of natural therapies is to reduced your need for medications.)
- Make sure that the surface of your skin is clean and dry when you arrive for your appointments, as the therapist will need to easily grip and move the skin and underlying fascia throughout the treatment. If the therapist's hands slide across the skin, the treatment will be less effective.
- Arrive 15 minutes early for your first appointment to read and sign agreements.
- Arrive to all appointments well rested and hydrated (you can enjoy Berkey-filtered water with or without electrolytes, and herbal or green tea while you are here)
- Bring a 3-ring binder and page dividers with you to all your appointments, which will contain detailed reports from all previous appointments for easy reference (it's okay if you don't have this for your first appointment, but it will be helpful to have by the second time, as you'll be given a lot of articles and information right off the bat)
- Optional, but highly recommended: There probably won't be time to do this on your initial appointment, so plan to do this on your second visit - bring all your nutritional supplements to be tested against your meridians to determine if you're taking the right supplements and brands. This takes all the guesswork out of your investment in this aspect of your health!

CONFIDENTAL CLIENT INTAKE
Part 1 of 5 - Personal information (required)
Appointment Date (if you have not yet scheduled your appointment, do so here: https://www.transformationswellness.net/schedule/):

MonthDay Year
Date
Who is filling out these intake forms for you?*

I am filling them out myselfSomeone else is helping me to fill them out
Name*

First Name Middle Name Last Name
Preferred Nickname (how would you like me to address you?)
Biology:

I have a penisI have a vaginaI have both male and female sex organs
Date of birth:

MonthDay Year
Date
Address

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Preferred Phone Number*
Please enter a valid phone number.
Alternate Phone Number (optional)
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contact Person - name
Emergency Contact Person - relationship to you
Emergency Contact Person - phone number
Your Occupation
What do you do with your body all day long at work and/or at home? (This helps me determine where you likely carry your stress and which types of injuries you're more likely to experience.)
If you are a first-time client, who may I thank for referring you? (Where did you hear about me?)

CONFIDENTIAL CLIENT INTAKE
Part 4 of 5 - Biofeedback & Quantum Energy Healing Demographics
YOU MAY SKIP THIS PAGE (Part 4) IF YOU ARE CURRENTLY PREGNANT

(to skip this page, scroll to the bottom and click "Next")

The addition of Biofeedback to your manual therapy appointment allows me to gather a lot of information about what is going on with your body and your health. You'll receive a detailed Biofeedback & Treatment Report after each appointment which allows you to see how you're progressing over time, including where you're improving and where you need more work. Quantum Energy Healing is also part of your Biofeedback and manual therapy session, which means you get 2 treatments simultaneously for the price of one!

Your Biofeedback Scan will reveal to me, among other things, which of your muscles are acutely or chronically stressed. This means that I no longer need to spend 30+ minutes of your treatment time searching for the source of your problem with my hands. (Remember that the source of your problem is rarely ever in the same place where you experience the symptoms!) For you, this translates to a more efficient, effective, and longer-lasting treatment.

DETAILS ARE IMPORTANT, as they are with numerology, astrology, and biorhythm tracking. Please answer all questions fully and completely, to the best of your knowledge & ability.
Please enter your current FULL LEGAL name (full first, full middle, and full last):
Do you have a pacemaker, seizure disorder, or are you currently pregnant? (Checking "yes" disqualifies you from receiving biofeedback or quantum energy healing, but you can still receive services like manual therapy or hyperbaric oxygen. If you checked yes, you can skip the rest of this form.)

yesno
The answers to the following questions are important for customizing your biofeedback scan, in order to get accurate results. Please answer each question as accurately as you can.
Please rate your negativity (0-10):
Do you have one or more known inherited disorders?

yesno
Are you a professional athlete?

yesno
Please rate your current happiness (0-10)
How many of your organs have been removed? (ie - appendix, tonsils, ovaries, uterus, etc)
Number of synthetic drugs used currently, including over-the-counter types ("synthetic" does not include natural plant medicines or supplements. You don't need to list them, just type a number.):
Average number of cigarettes, cigars, or joints smoked daily:
Number of steroid-type drugs used in the last year:
Number of metal amalgam fillings present in your mouth during last year:
Number of street drugs used per month:
Number of all known allergies:
Number of unresolved mental factors (anger, greed, desire, sadness, fear, etc)
Rate your agreement to this statement: "I am responsible for my body" (0-10)
Average daily servings of whole plant foods in diet (unprocessed fruit, vegetables, whole grains, nuts, seeds, etc):
Percentage of fat in diet, including processed foods (average is about 30%):
Rate your personal stress (0-10):
Average number of sugar products consumed daily (includes white flour/bread products, soft drinks, ice cream, pastries, etc):
Average number of exercise sessions weekly (20-minutes or more, do not include work):
Average number of alcoholic beverages daily:
Average number of caffeinated products per day (coffee, tea, cola, chocolate, etc)
Average number of extreme toxic exposures per year (radiation, chemotherapy, insecticides, chemicals, accidental exposures, etc)
Number of major injuries in past (include surgeries and emotional trauma)
Number of major infections, past and present (Include STD's and all health- and life-threatening infections. You don't need to list them - just type a number.)
Average number of 8-ounce glasses of water or natural (not bottled) fruit juice daily:
If you consider yourself overweight, how many pounds over your ideal healthy weight are you currently? (enter "0" if not applicable, or if you are underweight. This is YOUR opinion - not your doctor's opinion.)
Birth location (city and state):
Time of birth (if known):

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CONFIDENTIAL CLIENT INTAKE

CONFIDENTIAL CLIENT INTAKE