Intake Form Preferred Name * First Name Last Name Pronouns * Legal Name * First Name Last Name Current Gender Date of Birth * month/day/year format Sexual Orientation Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Occupation Emergency Contact Preferred Name * First Name Last Name Emergency Contact Pronouns * Emergency Contact Legal Name * First Name Last Name Relationship to Emergency Contact * Emergency Contact Phone Number (###) ### #### Reason for Appointment * Referred by Have you experienced CranioSacral Therapy before? Yes No List any allergies List any sensitive/painful areas Are you taking any medications? If so, please list. Have you had any surgeries? If so, please explain. Have you been in any car accidents? If so, please explain. Have you had any falls? If so, please explain. Have you had any injuries? If so, please explain. Have you had a concussion/brain injury? If so, please explain. Are there any other conditions/symptoms you would like me to be aware of? Please check any that apply. * Stress Anxiety Fatigue Joint Pain Heart Disease Autoimmune Disease Chronic Illness Gender Dysphoria Depression Headache/Migraine PTSD Covid Please read through the following statements: - I understand that CranioSacral Therapy is not meant to be a replacement of medical examination, diagnosis, or treatment. Written permission from my primary health care practitioner may be required for clearance of contraindications. - I agree to offer 24 hours notice for canceled appointments with exceptions for emergencies and positive covid tests or exposures. I understand that less than 24 hours notice will require a payment of 50% of my scheduled appointment price. I acknowledge that repeated cancellations with short notice may result in termination of services from Red Maple CranioSacral. - I affirm that I have stated all of my known medical and other health conditions and have answered all questions honestly. - I agree to keep the practitioner updated on my medical profile and understand that there is no liability on the practitioner if I fail to do so. - I understand that if at any moment I feel pain or discomfort, I can express my concerns and my session will be adjusted immediately to accommodate my requests. - I 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 full payment of the scheduled appointment. - If I am under the influence of alcohol or non prescription drugs, the appointment will be canceled. - I am responsible for practicing proper hygiene at the time of my appointment. - I understand that payment is required after I receive my invoice from Red Maple CranioSacral. - I understand that Red Maple CranioSacral will not tolerate violence, aggression or threatening behavior of any kind and I will be asked to leave immediately and to not return if I am unable to comply with this statement. By typing your name below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. * * Thank you for completing this intake form. Please contact us with any questions. We look forward to seeing you soon!
