First-Time Client Intake Questionare

Please take a moment to answer the general health questions and review and agree to our policy's and procedures.  Filling out this form PRIOR to your treatment will allow for more time with you during your initial session.  Thank you!

NOTE: Prior to treatment please remember to remove excessvie jewelry; pull long hair back and wear modest, loose comfy clothes for freedom of movement. 

Name *
Name
Are you under the care of a physician? *
Do you have any special medical needs or considerations? (i.e. use wheelchair or walker, have shortening / hardening of muscles known as a contracture, etc) *
Have you ever had a stretch session? *
Are you or do you think you are Pregnant? *
Do you suffer from any seizure disorder/epilepsy? *
Are you Diabetic? *
If Yes - Is it under control?
I understand that fascial stretch therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation, assist in greater stretch gains of range of motion and energy flow. *
If I experience pain/discomfort during the session, I will immediately inform my therapist so that pressure can be adjusted to my level of comfort. I will not hold my therapist liable should I choose to not say anything if I have pain/discomfort. *
I have notified my therapist of all known medical conditions. I agree to inform my practitioner of any changes in my health and medical condition. I understand that there shall be no liability on the therapists part should I forget to do so. *
I understand that stretch therapy sessions are non-sexual in nature. *
I understand that there is a 24-hour cancellation policy. If I am unable to cancel before that time I will be responsible for the costs associated with that session and may be required to pay prior to any additional sessions. *
I understand that if I have purchased a package deal, my missed or late cancelation will be counted as one of the sessions. If I arrive late to my appointment, only the alotted time remaining will be utilzed and I'm responsible for the full payment. *
Yes
I understand that the services offered today are not a substitute for medical care and are not billable to my insurance. *
I understand that my practitioner is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. *
I am over the age of 18. If the answer is No - you MUST be accompanied by an adult. NO EXCEPTIONS. *