Client Intake Form

Patient Name

First NameLast Name

Date of Birth

Date

Occupation

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Person

First NameLast Name

Emergency Contact Phone Number

Format: (000) 000-0000.

Relationship to the Patient

What is prompting you to reach right now?

Are there any current injuries, flare-ups or recurring limitations that I should know about?

What would a successful session feel like for you, even on a hard day?

The following questions help me prepare for your session. Answer only what feels relevant, there are no required fields in this section.

Do you have any of the following conditions?

Please describe any conditions you indicated above, including relevant history, timeline or context.

Are you pregnant, breastfeed, or nursing?

Are you wearing any implantable medical devices? If yes, what are these devices?

Current medications?

Past surgeries or significant scarring? If yes, please indicate the name or location of the surgery:

I understand that the services provided by Elizabeth Myers may include therapeutic massage, craniosacral therapy, biofield tuning, visceral manipulation, progressive strength training, mobility work, and related movement and bodywork modalities. These services are intended to support tissue health, nervous system regulation, mobility, strength, and resilience.

I have informed Elizabeth Myers of all known physical conditions, medical conditions, and medications, and I will communicate any changes as they occur. I understand that there shall be no liability on the part of the practitioner due to my forgetting to relay pertinent information.

I understand that all services provided are therapeutic and professional in nature. Any inappropriate remarks or behavior may result in immediate termination of the session. In the event of such termination, full payment is expected regardless of whether the session was completed.

If I experience any pain or discomfort during a session, I will immediately communicate that to the practitioner so that adjustments can be made.

I understand that movement based sessions including strength training, mobility work, Pilates, and yoga involve physical activity that may at times be strenuous and carry some risk of injury. I agree to take full responsibility for communicating my limits and for my participation in all movement activities.

I understand and agree that Elizabeth Myers is not responsible for any personal injury or loss of property sustained during any session.

Cancellation Policy: I understand that 24 hours notice is required to cancel or reschedule an appointment. Failure to provide adequate notice will result in a full charge for the missed session.

I have read this intake and informed consent form, fully understand its contents, and agree to the conditions of treatment outlined above.

I confirm that all information given in this form is true, complete, and accurate.
I released this organization for any responsibility in case of accident, illness, or injury.
I acknowledge that no assurance was offered about the outcome.

Signature of the Patient

Parent/Guardian Name

First NameLast Name

Signature of Parent/Guardian

Patient Data

Health History

Wavier of Liability and Informed Consent