New Client Form Name * First Name Last Name Email * Phone (###) ### #### Birth Date * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact First Name Last Name Phone (###) ### #### Which of these are you seeking assistance with? * Relief/improvement from physical symptoms Improvement of my emotions/mental wellbeing Greater ability manage relationships & stress Reduce tension & stress Better posture & greater flexibility Personal &/or spiritual growth and development Greater life enjoyment Improved overall health & wellbeing What are the main reasons that have brought you to see me? * Physical History * Describe any significant history concerning your physical body (include any accident, medical intervention, medication, symptoms, toxin or drug exposure) If you have been experiencing pain, what are the levels of pain from 1-10? Type of pain Sharp Dull Ache Burning Numbness Stiffness Constant Intermittent Weakness Pins and Needles What would you rate your general physical health? Excellent Good Fair Poor Mental/Emotional History * Describe any significant history concerning your mental and emotional life (include any major life stresses, traumas or events, as well as any medications or mental & emotional symptoms) * How is your mental and emotional life presently? Please include any current mental health challenges, diagnoses and medications) * How would you rate your general emotional/mental health Excellent Good Fair Poor * What would your main goal/s for the future be for your mental and emotional life? Lifestyle Do you consume alcohol, coffee, cigarettes, marijuana, any other drugs/substances? If yes, how often for each? Are you currently taking any prescription or over the counter medications? If yes, what kind and for how long? * Do you have trouble falling &/or staying asleep? Do you lucid dream or astral project? * What would you rate your stress levels out of 10? Past & Present Health Team * What type of practitioners and health care providers have you consulted in the past and how helpful have they been? Additional Information Is there any other information which you feel may be relevant to your care here that has not been covered? Informed consent By signing this form, you are stating that you give consent for our practitioners to treat you using the Spinal Energetics technique. This technique is a gently/no touch energy healing technique that unwinds tension patterns along the spine in a safe and gentle way to release past trauma, reduce stress and increase your overall quality of life. Thank you! Emotional Release Therapy - Inner Child Work Name * First Name Last Name Birth Date MM DD YYYY Email * Phone (###) ### #### Profession * Health/ Physical Issues * Option 1 Option 2 Emergency Contact Do you have Emotional Release experience * Yes No What do you use to keep your feelings down? How are you emotionally resourcing yourself if you are struggling? therapist, friend, somatic exercises) Anything else you will like to share? Release of Liability * I am solely responsible for my health and safety and I agree to not hold the practitioner responsible for any loss, injuries, or illness that may occur as a result of my participation in the bodywork session. I understand that this work is hands on and may result in superficial bruising, tenderness, or short term muscle soreness. I agree to not hold the practitioner responsible for any exacerbation of undiscovered injury. Either I, or the practitioner may choose to terminate the session at any time. Please note: To ensure safe and sacred space, we ask that you abstain from alcohol or drugs during or prior to treatment. To avoid being charged, please allow for a minimum of 24 hours notice for canceled appointments. Thank you!