new client intake form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Birthday * MM DD YYYY Email * Phone (###) ### #### Have you experienced Craniosacral Therapy before? * Yes No What brings you to Craniosacral Therapy? * Previous operations/surgery or major accidents/injuries/broken bones or scar tissue (include approximate dates): Please list any chronic or recurring conditions, immune disorders or genetic conditions: Describe any other physical, emotional or mental health events that you feel comfortable sharing: Describe what you know about your birth experience (i.e., natural, C-section, with epidural, pre/post birth complications, medical interventions)? Are you wearing contacts? Are you wearing dentures? Are you pregnant? Please check any of the following boxes if you currently have or recently had any of the following symptoms. Add details if pertinent. This information helps inform our work together, but you are not required to answer anything that you don't wish to. HEAD AND NECK Headaches and migraines Ringing in ears Hearing loss Vertigo or dizziness Vision Issues Whiplash History of braces Head and neck details CARDIOVASCULAR High or Low blood pressure History of heart attack Heart disease Poor circulation Raynaud's Easy bruising Varicose veins Cardiovascular details RESPIRATORY HEALTH Asthma or shortness of breath Chronic cough Lung disease Sinusitis Chronic ear or sinus infections frequent colds or upper respiratory infections Respiratory details MUSCULOSKELETAL SYSTEM Muscle or joint pain Chronic pain Arthiritis Tendonitis Bursitis Jaw pain or TMJ disorder Muscle weakness Scoliosis or spine conditions Osteoporosis Sprained ankle (past or current) Musculoskeletal details NERVOUS SYSTEM Sensory loss or change Numbness or tingling Chronic fatigue Challenging sleep Sleep apnea Feeling jumpy or hypervigilant Sensitive to touch/pressure Fibromyalgia History of meningitis ADD or ADHD Dyslexia Neurodivergent Nervous system details MENTAL HEALTH Anxiety Depression Fogginess, difficulty concentrating Disassociation or numbness Racing thought or overwhelm Panic attacks Mood swings Memory loss Mental health details OTHER Long covid symptoms PMS or menstrual irregularity Endocrine or thyroid conditions Acid reflux Trouble swallowing Digestive issues Other details Any other information you feel I should know? ACCURACY OF INFORMATION * Because a Craniosacral therapist must be aware of existing physical conditions, I certify that the above medical information is correct to my knowledge, and I take it upon myself to keep the Betsy updated on any changes to my health. Further, I release Betsy Power from responsibility and liability for any adverse reactions resulting from disclosed and undisclosed conditions. CONSENT FOR TREATMENT * Please check each of the following paragraphs after thoroughly reading. I understand that the Craniosacral therapist does not diagnose illness, disease or any other physical or mental disorder. In addition, the Craniosacral therapist does not perform spinal or skeletal adjustments, prescribe medical treatment or pharmaceuticals. It has been made very clear to me that the Craniosacral therapy provided includes techniques that are hands-on in nature and that my or my child’s service will include hands on touch techniques. I understand that Craniosacral therapy is considered to be a contraindication for recent injuries to the head and neck, i.e.; recent whiplash, any recent fracture to the base of the neck, concussion or hemorrhage and state that I am not currently experiencing any of these conditions. It has been made very clear to me that Craniosacral therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure may be adjusted to my level of comfort. If I feel uncomfortable at any time during the session, it is my responsibility to notify the therapist, and if I request the treatment to cease, the therapist will end the session. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care. PRIVACY AND SHARING INFORMATION * I authorize Betsy Power to collect my personal and medical information as documented above. I understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission. SERVICE AGREEMENT * Cancellation Policy: I agree to notify Betsy within 24 hours if I need to cancel an appointment. If I am unable to do this, I understand that I will be responsible for payment for the scheduled time unless Betsy is able to fill the appointment time. I have read and understand this cancellation policy. I understand that these services are not billable to medical insurance, and I am responsible to pay all balances. I understand payments are due at the time of service. Payments should be made by cash or venmo @betsy-power-1). Rate as of November 1, 2024 for 1 hour session is $120 SUBMISSION Please submit form to be signed and dated during our first session. Thank you!
