Client Intake Form for Initial Consultation

Once you have completed and submitted this form, please email me to schedule. See the Information and FAQ link for more information.

Personal Information for Initial Consultation

First Name

Last Name

Date of Birth

Sex Male Female

Height

Weight

Please provide the following contact information. I contact via Email, so email address must be provided for contact.

Work Phone or

Home or Cell Phone

E-mail

Which Sensual Session type are you requesting:

How often do you receive massage:

I have never received a massage
A few times a year
About once a month
Once a week or more

Select any of the following options that apply:

I am allergic to peanuts of other nuts
I have other allergies
I have skin irritations
I have arthritis and/or joint disorders
I have high blood pressure and/or heart problems
I have varicose veins and/or blood clots
I have spinal problems
I have frequent headaches
I am currently under a doctor's care
I have had recent injuries and/or broken bones
I have had recent surgery

Do you smoke?

Yes
No

List any areas of pain, stress, or discomfort as well as medical conditions - along with medications.

What physical activities or hobbies keep you engaged?

Have you worked with energy or received any energy work? What type if so:

What do you do for a living? What would you enjoy doing?

What do you do to develop yourself spiritually?

How do you hope to benefit from my services?

Which sessions type? Please list any other comments:

If receiving massage, please indicate what type of draping you would prefer?

How will you pay?

How did you find my website?

AGREEMENT:

By submitting this form, I agree and acknowledge to the following: (Form Submission is the same as my electronic signature.)

I understand that my session begins and ends at a certain time and that my being late does not extend my time.

I am subject to a 100% fee if I do not show up to my scheduled appointment.

I understand that my coach/therapist provides exactly what is described on the website, and that I have no other expectations.

I understand that fees are for services as advertised only.

If I am uncomfortable for any reason, I will ask for the session to cease immediately.

I will make my coach/therapist aware of any and all electronic devices.

I will turn off all electronic devices while in session.

I have listed all of my medical conditions on this form and will update my coach/therapist should any new conditions arise prior to this session or any future sessions.

Client Intake Form for Initial Consultation

Revised: 05/07/12