Patient Intake Form Name * First Name Last Name Age * Pronouns She/Her He/Him They/Them Occupation Email * Phone (###) ### #### Emergency Contact * Name/Phone Number/Address/Relationship Please list any allergies Are you currently experiencing any pain or discomfort? Are you currenly living with chronic illness? Please list any medications or supplements you are currently taking What is your birth order? Did you share a home with your siblings? ex. Oldest of three but I moved out before my youngest sibling was born What are you looking to focus on in our sessions together? Are you sensitive to scent or smoke? Specifically referring to essential oils, incense, candles, sage, etc. Are you comfortable with me touching your hair? Yes No Other Are you currently or have you previously worked with a mental health professional? Are there any areas of your body that I should avoid? Is there anything else you'd like to share with me before our session? Statement of Understanding Informed Consent * 1. I understand that the information provided in this form will be kept confidential and will only be used for the purpose of my session with The Practice. 2. I consent to receive hands-on body therapy from any practitioner at The Practice and I know that that I can revoke this consent at any time. 3. I understand that I have the right to stop the session at any time if I feel uncomfortable or experience any pain. 4. I acknowledge that I have provided accurate and complete information to the best of my knowledge. 5. I understand that body therapy may cause some discomfort or soreness. I have been informed that the practitioner will use pressure that is comfortable for me and that I should communicate with the practitioner if I experience any pain or discomfort during the session. 6. I understand that during the session my practitioner may share “intuitive downloads” that she may share them with me. These downloads may but not limited to emotional, physical and visual sensory. These are intended to serve as guidance and they may or may not resonate with me. 7. I understand that the practitioner is not responsible for any harm or injury that may result from the session. 8. I understand that sessions with The Practice should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I have read and consent to all of the 8 statements listed above. Thank you!
