• Client Info

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  • Medical History

  • Emotional Health History

    Answer as much as you feel comfortable sharing. Answers kept strictly confidential.
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  • Treatment Goals

  • Policies & Authorization

  • I acknowledge that distance healing based on craniosacral therapy and somatic bodywork is not a substitute for medical examination, diagnosis, or treatment or for qualified mental health care. Because body-oriented modalities should not be performed in the case of certain medical conditions, I affirm that I have disclosed all my known medical conditions and release my practitioner from liability for adverse reactions related to any disclosed or undisclosed conditions. I take full responsibility for informing my practitioner of any changes in my health status. Understanding all of this, I give my consent to receive care.

  • Your electronic signature is the equivalent of your ink-on-paper signature. Please provide it by drawing your name below. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document.

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