BREATHE.

Intake Form

Please fill out all of the following information before our session together. Questions? Email me at emilymasonpolarity@gmail.com
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Birth Date

MonthDayYear
Astrology Chart information: Time of Birth (if known)
Astrology Chart information: Place of Birth*
Your occupation*
Your emergency contact name and phone number*
Your relationship status*
Number of Children and ages*
Please list all medications, herbs, supplements you are currently taking*
Do you smoke or self-medicate with any substance(s)?*

YesNo
If yes, please explain type and use
Have you had a recent major surgical procedure, hospitalization or injury?*

YesNo
If yes, please explain
Have you ever received ... (Check all that apply)*

ReikiAstrological CounselingTherapeutic BodyworkBodyMind CenteringSomatic TherapyPerinatal TherapyQuantum Energy MedicineSomatic PsychotherapyPolarity TherapyMovement TherapyNone of the aboveOther
Are you currently seeing a Chiropractor, Physical Therapist, Physician, Psychiatrist, or other Alternative Practitioner for an ongoing issue?*

YesNo
If yes, what is the issue and what sort of practitioner are you using?
Are you sensitive or allergic to any scents or oils?*

YesNo
Any other known food/drug allergies?*
Do you have any of the following today?*

skin rashcold/fluopen cutssevere painanything contagiousinjuries/bruisesnone of the aboveOther
What are your intentions for this session?*
What brings you ease, joy, inspiration, or sense of belonging in your life? What are some resources that you can tap into (from any realm - seen or unseen)?*
Do you have animal companions in your life?*

YesNo
Do you have a reflective or mind/body practice of any kind?*

YesNo
What do you do for movement/exercise?*
What is your stress level?
Are you currently under an emotionally intense period or transition in your life? How are you supporting yourself or managing during this time? List some of your resources.*
Have there been any big changes or losses recently in your life? (Living situation, work, family, relationships)*
If you know about your birth process, please share any information you can; complications, trauma, medical interventions as well as what was happening in your family emotionally or psychologically.*
Do you have a history of mental, emotional, physical or sexual abuse? Please share whatever feels right around this topic.*
Check the following conditions that apply to you, past and present. Please add your comments after all the 5 checkbox sections to clarify the conditions.
EARTH*

Knee pain/accidents/surgeriesSpastic colon/colitisLoss of balanceAcneDifficulty letting goNeed for supportIntestinal gasOverly structuredConstipation/DiarrheaFearAttachment IssuesNone of the above
WATER*

Feeling OverwhelmedDiminished libidoOut of touch with feelingsBladder issuesEdemaCancerBlocked intuitionDepressionPMSEndometriosisMenopausal/hot flashesBreast cancer/historyBreast issuesProstate issuesPainful testiclesSelf care needsAddiction or family history ofNone of the above
FIRE*

Facial twitchingHeart attackLack of motivationLight sensitivity/visual issuesStomach issues/IndigestionChest painHeart palpitationsAlcoholism/family historyEmpowerment issuesCold hands/feetLiver issuesPower issuesSinus issuesAnger issuesFatigueGallbladder issuesDiabetesSelf esteem/worth issuesNone of the above
AIR*

Communication issuesankle issues/sprains/injuriesIssues with greedHeadachesAsthma/shortness of breathCoping issuesShoulder tensionSmoking/historyAnxiety/nervousnessDrug useFeeling ungroundedRespiratory issuesInsomniaHeart problemsRelationship difficulties/tensionNone of the above
ETHER*

Sore throatTightness in throatGrief/lossSwollen jointsRinging in earsHearing issuesArthritisSpiritual conflictHormone issuesThyroid issuesFeeling of needing more spaceCreative blocksHeadachesNone of the above
Please add your comments to clarify ANY of the condition(s) you checked off in any of the 5 sections (earth, water, fire, air, ether) above.
Is there anything else that you feel would be helpful to share with me before we work together?
Waiver of Liability and Acceptance of Responsibility
I understand that a Somatic Therapist, Perinatal Therapist, Polarity Therapist, Astrologer, Reiki Practitioner, LMBT, or RYT does not diagnose disease, illness, or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand that draping will be used at all times if I am undressed. I understand that consent and boundaries will be utilized in these sessions. I understand that if I become uncomfortable for any reason that I may ask the Therapist to end the session. I understand that the Therapist may end the session for any inappropriate behavior. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the health care provider of any changes in my status.

I acknowledge and agree that I am voluntarily participating in the therapeutic session, movement/yoga class or workshop offered by Emily Mason. I agree to take care of myself. I take full responsibility to not exceed my limits in the practice of yoga or other therapeutic movement instruction and for any injuries of discomfort I might experience in practices. I am fully aware of all the risks and hazards involved.

I understand and accept that physical contact between the student and instructor or therapist and client will be offered for added support during sessions and classes. I consent to such contact and recognize that the instructor/therapist will apply any necessary contact in a professional manner. I knowingly, voluntarily, and expressly waive any claim I may have against Emily Mason for injury or danger that I may sustain as a result of participating in any movement/yoga class, workshop or therapeutic session. I, my heir(s), or legal representative forever release, waive, discharge, and covenant not to sue Emily Mason for any injury or death caused by their negligence or other acts.

Your privacy is deeply respected and honored. I understand that all information shared is absolutely confidential unless the therapist and I sign a written consent.

I take full responsibility for my belongings.
Your full name typed out (serves as signature)*
Today's Date*

MonthDayYear
Date
Should be Empty:

Check the following conditions that apply to you, past and present. Please add your comments after all the 5 checkbox sections to clarify the conditions.