New Client Intake Form
Please print out this form and bring it with you on your first visit.

The intention of this form is to gather information about yourself that you feel comfortable sharing so that
together we can work to achieve your goals in regard to healing.  Feel free to share to your comfort level any
physical, emotional, spiritual concerns you may have.  I honor your trust with great presence and awareness.
Always with gratitude and respect. Kathryn



Name (please print):_______________________________DOB:___________
Address:_______________________________________________________
Home Phone:__________________ Cell Phone:________________________
Email Address:_________________________ Occupation:_______________
How did you connect with cup of life? _________________________________

Have you received professional bodywork in the past?____________
What modality?
__________________________________________________________________________

What is your intention for this treatment?  Relaxation     Pain Relief    Balance   
Stress Relief           Other:______________________________________________________
Please Explain:______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Where in your body do you feel pain, stress or tension?:______________________________
__________________________________________________________________________
__________________________________________________________________________

Please list any major medical conditions, broken bones, surgeries or accidents you’ve had:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________

Please list any medications and supplements you are currently taking:____________________
_____________________________________________________________________________________
_________________________________________________________________

Please list exercise you practice on a regular basis:__________________________________
__________________________________________________________________________                           
                                                            

Do you have any of the following conditions? If yes, please circle the condition:
Heart Condition                      Skin Condition                          Varicose Veins
Diabetes                                 Edema (Swelling)                     Asthma
Epilepsy                                  Sciatica                                    Headaches/Migraines
Arthritis                                   High Blood Pressure                Low Blood Pressure
Scoliosis                                 Pregnant?                                Numbness/Tingling
Sinus Problems                      Excessive Stress                      Blood Clots
Seizures                                 Circulation Disorder                 Contagious Disease
Hepatitis                                 Cancer                                     Fibromyalgia
Osteoporosis                         TMJ Disorder                             Other:


Please explain any condition you have circled, including treatments:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________


Holding the intention of creating a professional and therapeutic space,  I ask you to read and initial the
following statements to indicate your understanding and agreement of them:

I am aware that Kathryn’s treatment is for the purpose of stress reduction, relaxation, balance and increase
circulation and energy flow. ________  (please initial)

I understand that my feedback, as well as my comfort, are essential elements of my treatment.  If at any time
during the session I become uncomfortable for any reason, it is my responsibility to bring it to Kathryn’s
attention immediately. (ie. Pressure,  room temperature, feelings/emotions, etc.) ________   (please initial)

If I am unable to keep my appointment, I understand that a 24 hour notice is required, or I will be charged for
the appointment at the regular rate. ________  (please initial)

Waiver: I understand that Kathryn will not diagnose illness, disease, physical or mental disorders, nor does
she prescribe medical treatment, medications or perform spinal adjustments.  Bodywork is not a substitute
for a medical exam or diagnosis.  I take responsibility for alerting Kathryn to any physical, mental or emotional
changes that occur with my health in the course of treatment. I do hereby state that the above information is
true and complete to the best of my knowledge and that I will not hold Cup of Life and/or Kathryn Gabriel liable
for any injury arising from my treatment. I acknowledge that my choice to participate in treatment is my
complete personal responsibility and participation is at my own risk. On behalf of myself and all others in
legal relationship with me, I hereby release Cup of Life and/or Kathryn Gabriel and all affiliates from any and
all liability for any injury, emotional or physical, which may occur to me while I am a client of Cup of Life/Kathryn
Gabriel or as a result of using any information or instructions I receive from them.  I declare that I have read
and understood and agreed to the contents of this waiver in its entirety.


Signed:_________________________________Date:___________________