Appointments
About Lauren
More Info
Appointments
About Lauren
More Info
Client Intake Form
Name
*
First Name
Last Name
Date
*
Today's Date
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DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
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Email Address
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Occupation
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Emergency Contact
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Please provide your emergency contact name, phone number, and relation to you
Referred by
What is the goal for this session?
Where are you holding tension in your body?
Please list any surgeries, injuries, accidents or hospitalizations you have had: Less than 5 years ago:
More than 5 years ago:
What kind of care did you receive for your injuries?
Do you feel that you have recovered from these events?
Do you have any chronic, ongoing pain? Where?
What activities make the pain worse?
Are you receiving any other type of medical treatment?
Please list any medications, herbs, supplements you are currently using:
Please check any of the following conditions that affect you currently, or in the last 5 years:
Musculoskeletal
Fibromyalgia Anemia
ALS
Ulcers
Spasms/Cramps Hypertension MS
IBS
Sprains/Strains
Low Blood Pressure
Parkinson’s
Colitis
Osteoporosis Raynaud’s
Bell’s Palsy
Gallstones
Osteoarthritis Varicose Veins
Neuritis
Hepatitis A/B/C
TMJ
Heart Condition
Brain/Spine Injury
Stroke
Bursitis
Blood Clot
Concussion
Please check any of the following conditions that affect you currently, or in the last 5 years:
Nervous System
Trigeminal Neuralgia
Rheumatoid Arthritis
Diabetes
Seizure Disorders
Please check any of the following conditions that affect you currently, or in the last 5 years:
Digestive System
Crohn’s
Tendonitis
Numbness/Tingling
Diarrhea/Constipation
Whiplash
Gas/Bloating
Carpal Tunnel
Food Allergies
Sciatica
Indigestion
Neck pain
Back pain Mid/Low
Headaches/Migraines
Leg Pain
Arm/Shoulder Pain
Hip Pain
Thoracic Outlet
Respiratory
Pneumonia
Insomnia
Sinusitis
Anxiety/Panic Attacks
Asthma
PMS
Breathing Difficulty
Grief Process
Bronchitis
Lyme Disease
Emphysema Cancer
Chronic Fatigue
Pregnancy
Lupus
HIV/AIDS
Edema
Liposuction
Postoperative Situation
Please list any other conditions:
Medical Disclaimer I, the undersigned, understand that the licensed massage therapy treatment provided by Lauren Hyman, is not meant to replace medical care and consultation. I agree that if I have a serious medical condition, I will consult my physician.
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Agree
Date
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MM
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YYYY
Print Name
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Initial
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Moon Studios Client-Facilitator Agreement
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CONSENT FOR CARE AND TREATMENT As your licensed CranioSacral therapist, I will complete an evaluation by examination and interview. Your individual treatment program will then be designed. I, the undersigned, do hereby agree and hereby give my consent for Lauren Hyman to CranioSacral Therapy and treatment considered necessary and proper in treating my physical condition.
Agree
Cancellation / No Show Policy
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All appointments are scheduled on a per-client basis. A minimum of 24 hours notice is required for cancellation. Cancellations made less than 24 hours or no show appointments will be charged the full session fee.
Agree
Payment
*
Payment is expected at the time of treatment or prior to if the appointment is scheduled online. You may pay with cash, check, MasterCard or Visa. Please make checks payable to Lauren Hyman. There is a $25 service fee charge for all returned checks.
Agree
Insurance
*
I am an independent therapist and do not bill private insurance, Workman’s Compensation, or Medicare. However, I will provide you with the necessary information so that you may submit the claim to your insurance carrier. Please contact your insurance carrier to verify the limits of your coverage.
Agree
Thank you!
Moon Studios Craniosacral Therapy
what is craniosacral therapy?
What to expect
How to prepare
Client Intake Form
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