Client Intake Form
Requested Appointment:
Client Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Current Activity Level & Relevant Medical History:
Please include any past or present injuries, medical conditions, a list of medications and/or limitations to be aware of to support your practice safely and effectively.
Primary goals for your session(s)
Please Select
Stress relief
Pain management
Flexibility
Strength
Other
Single Session Selection
Please Select
In-Studio (60 minute) $125
In-Home Private (60 minute) $155
In-Home Semi Private (60 minute) $175
Session options.
5-Sessions Packages (60 Minutes Each) | 10%
Please Select
In-Studio Private — $562.50 (Save $62.50)
In-Home Private — $697.50 (Save $77.50)
In-Home Semi-Private (2 Participants) — $787.50 (Save $87.50)
Session options.
10-Sessions Packages (60 Minutes Each) | 15% OFF
*
Please Select
In-Studio Private — $1,062.50 (Save $187.50)
In-Home Private — $1,317.50 (Save $232.50)
In-Home Semi-Private (2 Participants) — $1,487.50 (Save $262.50)
Session options.
STUDIO XI | ELXC — TERMS & POLICIES
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