• PLEASE READ!!!

    This page contains important need-to-know information. 

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

     

    If you are scheduled to receive a basic, relaxing massage service, only the first 3 parts of this online intake form are required. If you are looking for permanent correction of pain or posture problems, or if you're unsure about what you need, please fill out the entire 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:

    • Be sure to scroll all the way to the bottom of the last page to find the "Submit" button. Failure to click this button will mean that I won't receive ANY of your intake information.
    • 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)
    • If you have not already done so, schedule your appointment here: https://www.transformationswellness.net/schedule/

    For new clients:

    • Arrive 15-20 minutes early for your first appointment.

    For relaxing or therapeutic massage appointments:

    • No special instructions. Just wear or bring comfortable clothing to wear home after your massage.

    For all other appointments:

    • 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.)
    • Be 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 is sliding across the skin, the treatment will be less effective.
    • If you have one, please 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) If you don't have a binder, I will provide one to you if/when you enroll in any ongoing treatment program.
    • 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!
    • Plan to give yourself at least a 1-day break between sessions in order to allow your body time to heal and adjust to therapeutic changes.

     

  • CONFIDENTAL CLIENT INTAKE

    Part 1 of 4 - Personal information (required)
  •  - -
    Pick a Date
  •  - -
    Pick a Date
  • CONFIDENTIAL CLIENT INTAKE

    Part 2 of 4 - Health History (required)
  • COVID

  • FYI - I have NEVER taken a COVID shot and never will. In fact, I have suffered serious blood clot-related health complications as a direct result of working on recently vaccinated clients. If you have recently taken a COVID shot or booster, I ask that you please refrain from scheduling appointments to receive treatment in my office until at least 60 days have passed. Thanks for your understanding and cooperation.

  • GENERAL

  • SKIN

  • MUSCULO-SKELETAL

  • CARDIOVASCULAR

  • GASTROINTESTINAL

  • RESPIRATORY

  • EARS

  • CENTRAL NERVOUS SYSTEM

  • WOMEN

  • MISCELLANEOUS

  • CONFIDENTIAL CLIENT INTAKE

    Part 3 of 4 - Definition of needs and type of service
  • CONFIDENTIAL CLIENT INTAKE

    Part 4 of 4 - Biofeedback & Quantum Energy Healing Demographics
  • Skip this section if you're scheduled for massage or Hyperbaric Oxygen Therapy (HBOT).

    For all other appointment types, this section is required.
  • BE SURE TO CLICK "SUBMIT" AT THE BOTTOM OF THIS PAGE

  • 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.

  • 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.

  • NOTICE:

    If you have filled out this section carefully and thoroughly, AND you submit a close-up selfie of your face, I can begin running your quantum feedback scan before you arrive, which will save time and result in a more productive first visit. You can submit your selfie by e-mail to: relax@transformationswellness.net . Be sure to include your name and birth date in the e-mail so I can connect the correct image to your profile.
  • Should be Empty:
Jotform Logo
Now create your own Jotform - It's free!Create your own Jotform