session intake form

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Name *

First

Last

Address

City, State, Zip Code

Phone *

Mobile?

Is it ok to text appointment reminders?

Email *

Age

DOB

Occupation

Emergency Contact Name and Phone Number *

Are you curtrently under a physician's care for any condition? If yes, please describe *

Do you have current or history of any of the following health conditions? Check ALL that apply

Check ALL that apply

Are there any physical or mental conditions which the therapist should be aware of before proceeding with the treatment?

Read and check each box to acknowledge *

I understand that the therapist does not diagnose illnesses, diseases, or any other physical or mental disorders. In addition, the therapist does not prescribe medical treatments or pharmaceuticals.
I understand that manual therapy is considered to be a contraindication for recent injuries to the head and neck and that I am not currently experiencing any of these conditions.
It has been made very clear to me that manual therapies like craniosacral, massage, and visceral are not a subsitute for medical examination and/or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.
Because a therapist must be aware of existing physical conditions, I have stated all of my known medical conditions and take it upon myself to keep the therapist updated on my physical health. Further, I release the therapist from responsibility and liability for any adverse reactions resulting from undisclosed conditions.

I hereby acknowledge that my typed name below will act as an electronic signature to the information provided on this form to be true and correct. *

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