Bliss Move Program Client Intake Form

Bliss Move Client Intake Form
Thanks for trusting me and taking the time to fill this out.

All information stays confidential. I use this to understand your current state and tailor our sessions to your specific needs for a safe, effective experience.

I'll reach out within 5 business days to schedule our initial session, where we'll review your responses, ask questions, and do some movements so I can better understand what you need.

By submitting this form, you're committing to your chosen package. If we're not the right fit after our first meeting, simply email info@byiraiz.com within 48 hours.

I look forward to working together to achieve your goals.
* My availability opens on Weekdays(Monday to Friday).
* My time zone: PDT(UTC/GMT -7)
Personal Information
Name

First NameLast Name
Email
example@example.com
Age
You can put an age range if you prefer not to say your exact age
What do you do for work?
Which Option are you interested?
Help me understand your situation
If you have pain, where do you experience pain on your body? Or what do you most want to improve by working with me?
Is there a specific thing you're doing, or a certain time of day, when your pain feels the worst?
Examples: sitting at desk, getting out of bed, picking things up, driving, cooking, bending forward, twisting, getting up from floor, reaching overhead, squatting, walking up stairs, etc.
What have you tried to help relieve the symptoms, even temporarily?
Example: stretching, heat, rest, movement, massage etc.
What activities or "life things" do you want to get back to or enjoy more?
Examples: hiking, playing with kids, traveling comfortably, exercising without fear, sleeping well, etc.
What emotions come up when you experience pain and what do you do about it?
Examples: frustrated, anxious, hopeless, annoyed, scared, angry, sad, overwhelmed, etc.
How do you rate your stress level on daily basis? (Select the option which best applies to you)

1

2

3

4

5

1 is Low, 5 is Very High
How do you currently rest or recover? (e.g., sleep, downtime, hobbies). If you have trouble resting, when you're not doing anything, how do you typically feel?
Example: some people experience anxiety or restlessness when no doing anything
Your current movements/ activities
What physical activities are you currently doing (if any)?
Include frequency. Write "None" if you're not currently active.
How often do you engage in the forms of physical activity described above?
When you move, is it easy for your to tell which muscles are working?

Other
Your experience with other professionals
Have you received any treatment for this condition? (past or current)
Examples: physiotherapy, chiropractic, massage therapy, acupuncture, doctor visits, etc. Write "None" if you haven't seen anyone.
What have you learned about your body from those professionals?
Any insights, diagnoses, or explanations they gave you. Write "N/A" if not applicable.
What else have you tried to relief the symptom outside of treatments? What do you think that is not working for you? What made you decide to reach out to me at this time?
Medical History
Has a doctor ever told you that you have a sickness or condition connected to what's been bothering you?
Do any of these conditions apply to you? Please select all that apply
If you've checked any of the conditions listed above, please describe them in more detail. Please also list any conditions not mentioned above
Have you ever had any surgeries? If yes, please list what they were and when they took place
Are you currently taking any medication (prescribed or otherwise) or any supplements. If yes, please list them.
Working With Me
What do you want to learn about when it comes to your body, movement, and wellness?
If we meet online, what props or equipment do you have at home?
Examples: yoga mat, foam roller, resistance bands, yoga blocks, tennis ball, chair, towel. Write "None — that's okay too!" if you don't have anything.
What session frequency did you have in mind? (minimum is once per week)
What is your time zone?
Example: PDT (Vancouver), EST (Toronto), GMT+8 (Singapore). Skip if meeting in-person.
What days of the week and time ranges work for you?
⚠️ IMPORTANT: Please list SPECIFIC DAYS and TIME RANGES at your local time. Example: "Tuesday 6-8pm, Thursday morning 9-11am, Saturday flexible"
Is there anything else you want me to know before we meet?
Should be Empty:

Bliss Move Client Intake Form

Personal Information

Help me understand your situation

Your current movements/ activities

Your experience with other professionals

Medical History

Working With Me