Intake Form

Client Info
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Date of Birth

Month Day Year
Date
Occupation
Gender / Pronouns
Medical History
Medical conditions ( or symptoms that bother you ):
In particular, have you ever had any of these conditions?

Concussion or head injury HIgh blood pressure Whiplash Heart issues Neck pain Stroke Back pain Diabetes Sciatica Cancer Nerve damage Digestive problems
Significant accidents or injuries in your life:
In particular, have you ever experienced:

Bad fall Surgery Car accident Anesthesia Other type of bad injury
Recent surgeries:
Current medications, supplements, and treatments (traditional and alternative):
Birth story: What do you know about your own birth?
Emotional Health History

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

Typical stress level:

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Difficult life experiences / traumatic events:
In particular, have you ever experienced:

Emotional abuse (known or suspected) Chronic stress or anxiety Sexual abuse (known or suspected) Panic attacks Physical abuse (known or suspected) PTSD Other abuse (e.g., cult or ritual) Depression Prolonged or unexpected grief Suicidal feelings or thoughts Trauma re: race or ethnicity, gender, sexual orientation, religion Suicide attempts
Anything else about your emotional or mental health I might need to know?
Support in your life: What supports, comforts, or brings you enjoyment?
Treatment Goals
What would you most like help with?
Policies & Authorization
I understand that I must give 24-hour notice in order to cancel or reschedule my appointment and that, without adequate notice of change or cancellation, I will be charged the full session rate. (Exceptions may be made for emergency situations.) *

Yes
Would you like to subscribe to my email list? (About once a month, I email clients to update them about my practice, provide health tips and information, and offer promotional deals. You may unsubscribe at any time.) *

Yes No
If yes to above question, what email would you like me to use?
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.
Client Signature (if 18 or over)

Clear
Parent/Guardian Name

First Name Last Name
Signature of Parent/Guardian

Clear
Should be Empty:

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Client Info

Medical History

Emotional Health History

Treatment Goals

Policies & Authorization