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Energetic Methods Client Intake Form
Please use this form if you have an appointment with Energy Body Mind. All information is kept confidential.
FILL OUT BOTH PAGES AND HIT "SUBMIT" AT THE BOTTOM OF EACH PAGE FOR FORMS TO BE VALID
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Name
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First
Last
Address
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Phone Number
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City
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State
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Email
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Zip
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Occupation
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Emergency Contact Name
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Emergency Contact Phone Number
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How did you hear about us?
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Referral- who?
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Have you ever done yoga before? If yes, what kinds?
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Have you ever done any energy methods? If yes, what kinds?
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Please describe what goals you would like to achieve, and what are your challenges in achieving these?
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HEALTH HISTORY
Overall Energy Levels (1 low 10 high)
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Overall Stress Levels (1 low 10 high)
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How does your stress manifest?
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physical/mental/emotional
What are things you do that help you reduce stress?
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Do you experience any of these physical conditions?
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Headaches
Digestive Issues
Osteoperosis
Low Blood Pressure
High Blood Pressure
Degenerative Disc Disease
Scoliosis
Nerve Entrapment/Tingling/Numbness
Muscle Cramps/spasms
Buise Easily
Arthritis
Dizziness/Vertigo?
Trouble Hearing?
Do you experience any of these energetic issues?
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Going blank when trying to remember
Feeling sluggish/lack of energy
Feeling scattered/difficulty concentrating
Trouble sleeping
Sensitive to electronics
Jaw tension
Neck/throat tension
Shallow breathing
Acheyness
Sensitivity to different environments
Sensitivity to others energy
Fidgiting
Feeling nervous/anxiety
Other conditions/issues we should be aware of?
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Have you suffered an injury or fall in the last 6 months? If yes, please describe
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Have you had any surgeries? If yes, please describe
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Are you curerntly under a physican's care, if yes, what for?
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Are you currently taking any medications? If yes, what for?
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DISCLAIMER & SCOPE OF PRACTICE
I understand that the service I receive is provided for the basic purpose of relaxation, increase my range of motion, to increase my awareness, and to support my health. I understand that if I experience any pain or discomfort during yoga or energy methods, it's important to listen to my body and ask for support from the teacher. I understand that results vary by individual. There are no guarantees of specific outcomes, and that my participation signifies that I take full responsibility of my own wellness journey.
Yoga/energy methods are not a substitute for medical attention, examination, diagnosis, or treatment. I understand that yoga/energy methods are not a substitute for medical care and that I should consult a healthcare professional if needed, prior to beginning any yoga practice, movement or energy methods. The instructor is not qualified to prescribe or treat any physical or mental illness, and that nothing said in the course of this session should be construed as such. If issues arise apart from this scope, a referral of alternative methods to support your health may be encouraged. Because some actions 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 instructor updated to any medical changes during the session and understand that there shall be no liability on the instructor’s part should I fail to do so. I hereby release an discharge the instructor from any and all claims or causes of action that I may have arising out of my participation in these sessions.
By participating in these services I agree not to reproduce, redistribute, or resell any educational materials I may receive from Energy Body Mind to support my health and well-being. I further agree to not present or teach any of the methods instructed by Energy Body Mind as my own.
Signature
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Date
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POLICIES
Please read and sign below.
CANCELLATION POLICY
Any cancelled/rescheduled appointments within 48 hours of your appointment start time will be charged 50% of the service total cost.
Day-of cancellations will be charged 100% of the scheduled services.
CREDIT CARD POLICY
All clients will be required to have an active credit/debit card on file.
Clients who remove their cards linked to their profile will be contacted to add another card on file. If contact is unable to be made, any outstanding appointments will be canceled.
CASH POLICY
5% discount will be applied for clients paying cash.
ADDITIONAL MILEAGE FEE
Therapist’s travel outside of 20 miles from Chino Valley will incur a $20 fee.
CHILDREN/PET POLICY
For the safety of your children and pets, and for your relaxation, it is encouraged to keep them outside the treatment space.
CELL PHONES POLICY
Please silence all cellular devices and refrain from taking phone calls during your session.
NO-POLITICS POLICY
All services aim to create a calm and relaxing atmosphere. To support a peaceful environment, please keep all political conversations outside the treatments space.
Thank you for understanding and supporting a stress-free experience.
In order to accommodate all clients, these policies will be strictly enforced.
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Client Signature
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About Energy Body Mind
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Client Forms
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Massage Therapy
Energy Methods
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