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 Name
Last Name
Address
Street Address
Street Address Line 2
City
State / 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)
Chronic Cough
Shortness of breath
Bronchitis
Asthma
Emphysema
Long Covid
Other
Please describe any respiratory issues:
Cardiovascular (past or present)
High/Low blood pressure
Chronic congestive heart failure
Heart attack/heart disease
Phlebitis/varicose veins
Stroke/CVA
Cardiovascular aneurysm
Pacemaker/other device
Coldness in extremities
Other
Please describe any cardiovascular issues:
Digestive Conditions (past or present):
Crohn's disease
Diverticulitis
Irritable Bowel Syndrome
Colitis
Leaky Gut
Reflux
Celiac Disease
Stomach pains
Constipation
Please describe digestive issues:
Women (past or present):
Gynecological conditions
Pregnant
Birth trauma/difficult birth
Hysterectomy
PCOS
Other
Please provide detail:
Head/Neck (past or present)
Headaches/Migraines
Jaw Problems/TMJ
Whiplash
Vision problems/loss
Eye motor problems
Ringing in ears/Tinnitus
Hearing Loss
Fainting/Dizziness
Sinus problems
Facial pain
Dental Surgery/Issues
Concussions
Post-Concussion Syndrome
Closed head injury
Other neurological issues
Other
Please provide detail:
Other Conditions (past or present)
Epilepsy/seizures
EDS/Ehlere's Danlos Syndrome
Diabetes
Cancer (list type below)
Arthritis
Susceptible to colds/infections
High stress levels
Insomnia
Fatigue
Childhood trauma
Numbness/tingling/loss of sensitivity
PDD/Autism
Recurrent ear infections
ADD/ADHD/Hyperactivity
Sleep issues/restlessness
Depression
Anxiety
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.
CANCELLATION POLICY: Your scheduled appointment is reserved exclusively for you. A text reminder will be sent to you 24 hours before your session. Should you need to cancel or reschedule, please notify Patra via text 24 hours in advance or follow your session link. 24-hour notice must be provided to avoid a $90 ($130 for 90-min sessions) late cancellation fee. Clients who miss their appointments without giving any prior notification will be charged in full for the scheduled service. These fees must be paid prior to rescheduling.
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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