Intake and Policy Form

CranioSacral Therapy Intake Form

The information requested below will assist Patra in treating you safely. Please note that all information provided will be kept confidential unless allowed or required by law. Your written permission will be required to release any information.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
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Birthdate
How did you find Patra?
Primary Care Physician
Name and number
Why are you seeking CranioSacral Therapy?
Are you currently receiving treatment from another health care professional or therapist? If yes, please explain?
Medications, supplements, herbs, essential oils, etc you are currently on:
Conditions being treated:
Injuries (recent or past):
Surgeries (recent or past):
Respiratory (past or present)

Other
Please describe any respiratory issues:
Cardiovascular (past or present)

Other
Please describe any cardiovascular issues:
Digestive Conditions (past or present):
Please describe digestive issues:
Women (past or present):

Other
Please provide detail:
Head/Neck (past or present)

Other
Please provide detail:
Other Conditions (past or present)

Other
Please provide detail:
Please list any pins, artificial joints, spinal fusions, etc:
Known allergies or hypersensitive reactions:
Other diagnosed diseases or medical conditions:
Is there any other information Patra should know to better support you during your session?
I have completed the intake form to the best of my ability and knowledge and agree to inform Patra if any of the the above information changes at any time. I am aware that the bodywork I receive is for relaxation purposes only. It is not intended to diagnose, treat or cure. Any medical inquires and/or treatments should be directed to a medical professional.
POLICIES

Please be advised of the policies of this office. Your signature below signifies acceptance of these policies.
HOURS OF OPERATION: Sessions are available on Tuesdays - Fridays by appointment only. The hours are 11a-630p on Tuesdays and Thursday. Wednesday and Friday hours are 12p-630p. The final booking time is 5pm. Please schedule with Patra directly or visit patrahealey.com and follow the BOOK NOW link.
COMMUNICATION POLICY and CONSENT: By booking and receiving services, you agree to receive appointment-related communication from Patra: a craniosacral studio, including scheduling confirmations, reminders, updates, and service-related follow-up messages by email and/or text. These communications are used solely for the coordination of your care and appointments.
Email Updates
CANCELLATION POLICY: Your appointment time is reserved exclusively for you. A valid card on file is required for online booking. Appointment reminders are sent 24 hours prior to your scheduled session. If you need to cancel or reschedule, please provide at least 24 hours notice via text or through your appointment link. Appointments canceled with less than 24 hours notice are subject to a late cancellation fee of $90 for 60-minute sessions and $130 for 90-minute sessions. Clients who miss their appointment without prior notification may be charged in full for the scheduled service. Cancellation and no-show fees must be paid prior to rescheduling. New Client Sessions canceled with less than 24 hours notice are non-refundable.
PAYMENT POLICY: Payment is due at the time of service. Credit card payments are subject to a 3% processing surcharge. Cash and other fee-free payment options are always welcome.
LATE ARRIVAL POLICY: All sessions have a specific amount of time allotted. A late arrival may not receive an extension of time.
NO SHOW POLICY: Unanticipated events occur in everyone's life. Things happen that are out of our control. Please contact Patra if you are unable to keep your appointment, for any reason. Clients who miss their appointments without prior notification will be charged in full.
CHILD POLICIES: If you have children, you will need to find someone to care for them during your session. This is time set aside for YOU to focus on YOU. Children are not permitted in the studio during your session.
SESSION POLICIES: CranioSacral Therapy does not require the removal of any clothing. Shoes and glasses are suggested. Pressure, table temperature or music volumes are all adjustable upon the client's request.
Sexual interaction or discussion of any kind is NOT TOLERATED at any time. The session will end immediately and the client will be responsible for full payment.
All discussion during sessions will remain confidential. This is a safe space to express, share and release.
New Medical Conditions: It is the responsibility of the client to keep Patra informed of any medical treatment. Please provide written permission from the physician to continue with CranioSacral Therapy. Keeping Patra informed of any changes in your health is required.
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CranioSacral Therapy Intake Form

POLICIES