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:___________________