The purpose of the Intake enables me to better understand your health history and current therapeutic needs for the session. Please take a moment to provide the information below. Thank you!

Name *
Name
address
address
phone
phone
PRESENT STATE:
(1 is mild and 10 is worst)
LIFESTYLE:
select one
MEDICAL:
for ex: acid reflux, arthritis, blood pressure (high or low) cancer- if so what type, chronic fatigue syndrome, depression, fibromyalgia, lupus, TMJ, Thryoid (Hyper or Hypo), etc.
BODYWORK:
What is your preferred depth of pressure during the session? *
Note: communication to comfort level of pressure is highly valued and adjustable at any time during the session.
What kind of music would you enjoy hearing during your session?
please check all that apply.
Please enter your name in the box below indicating you have understood the terms and conditions.