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ABOUT
SERVICES
CONNECT
SCHEDULE
CONTACT
Innate Wisdom
Holly Strother, RN, CST, MIM
Intake Form
Name
*
First Name
Last Name
Pronouns
Email
*
Birthday
*
Please enter your date of birth (MM/DD/YYYY)
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Emergency Contact #1
Please state name, relationship + phone number
Emergency Contact #2
Please type name, relationship + phone number
What are your goals and intentions?
Check all that apply
Pain relief
Relaxation
Improved sleep
Therapeutic
Boost immune function
Inner exploration/curiosity
Mental focus/meditation
Mind/body awareness
Healing
Emotional Release
Expand Knowledge of Craniosacral Therapy
Increase Ability to Receive Healthy Touch
What tools, practices and activities do you use to relieve stress and maintain your wellbeing?
Have you ever had a craniosacral session?
Yes
No
What prompted you to schedule a craniosacral session with me?
Where in your body do you hold tension?
Health Questionnaire
The following questions help us to address concerns and assess any conditions that might be contraindicative to your craniosacral session. Please check all that apply and explain if necessary.
Do you have any of the following conditions?
Check all that apply
Open Scrapes, Cuts or Wounds
Contagious Disease
Contagious Skin Condition
Are you pregnant?
Yes
No
If so, when is your due date?
MM
DD
YYYY
Have you experienced any of these conditions?
Check all that apply
Asthma
Acid Reflux
Fibromyalgia
PMS
Headaches/Migraines
Recurrent Ear Infections
Recurrent Sinus Infections
Immune Disorders
ADHD
Autism
Anxiety
Panic Attacks
TMJ
Tinnitus
Allergies
Genetic diseases
Chronic Pain
Whiplash
Depression
Sleep issues
What were the circumstances of your birth?
Check all that apply
Vaginal
C-section
Natural without pain medication
Long labor
Quick labor
Hospital
Home
Describe if you have any allergies/sensitivities to oils, chemicals or scents
Surgeries and/or Injuries (include approximate dates):
Accidents, Traumas and/or Abuse you have experienced (include approximate dates):
Include emotional, mental, and physical
Medications you are currently taking and the conditions they are related to:
Other health concerns, mental/medical conditions and phobias that you have:
Checkbox
*
RELEASE OF LIABILITY I understand that the craniosacral therapy I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my session, I will immediately inform the therapist so that the pressure may be adjusted to my level of comfort. I further understand that craniosacral therapy should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a qualified medical specialist for any mental or physical ailment that I am aware of. I understand that craniosacral therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. Because craniosacral therapy should not be performed under certain medical conditions I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so. I agree to give 48-Hour notice if I choose to reschedule or cancel an appointment for any reason other than a family emergency or sudden illness. If I cancel without 48-hour notice or do not show up to my appointment I agree to pay the full cost of the craniosacral therapy session. I affirm the accuracy of the information I have provided and understand and agree to the policies above.
I attest that I have read and agree to the release of liability.
I do not agree with the release of liability.
Name
First Name
Last Name
Today's Date
MM
DD
YYYY
Thank you!