Into the Body | Trauma Healing

MonthDayYear

Full Name

First NameLast Name

malefemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

Phone Number

Area CodePhone Number

occupation

age

emergency contact

how did you hear about me?

Main reason for visit

Please list any other symptoms you are currently experiencing

Have you ever received professional bodywork before?

yesno

If yes, what kind and how recently

Are you currently seeing other health professionals about your symptoms?

Please rate your stress level

lowmediumhighextremely high

What kind of regular exercise or movement practice do you engage in?

Please list any surgeries, hospitalizations or serious illnesses - what and when

Please list any car accidents or other physical trauma or injuries

Please list briefly any other history of trauma ( physical, sexual, emotional or other)

Please list any medications you are currently taking

Policies and Agreements

1. I understand that I am responsible for payment of all professional services provided ( unless my treatment is covered by medpay or other eligible insurance).

2. I agree to give 24 hours notice of any cancellation or rescheduling of an appointment and I understand that I will be charged for the session if I fail to do so.

3. I understand that a bodyworker does not diagnose medical conditions, prescribe any medications or provide spinal manipulations. I also understand that bodywork does not serve as a substitute for a medical examination, diagnosis or treatment.

4. If I become uncomfortable during the session I will inform the therapist, so that pressure or techniques can be adjusted to my level of comfort. I may ask the therapist to end the session if necessary.

5. I affirm that I have stated all my known medical conditions and agree to keep the therapist updated with any changes.

Signature

Thank you, see you at your first visit!