CST Client Intake Form

Name *

First Name

Last Name

Prefered Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday *

MM

DD

YYYY

How did you hear about me?

Internet Search

Facebook

Friend

Flyer

Other

What are your goals and intentions? (check all that apply) *

Pain Relief

Relaxations

Sleep Better

Therapeutic

Boost Immune Fucntion

Inner Explorations

Mental Focus/Meditation

Mind/Body Awareness

Healing

Curiosity

Emotional Release

Expand Knowledge of Craniosacral Therapy

Increase Ability to Receive Healthy Touch

Have you had a craniosacral session before? *

Yes

No

Are you pregnant? *

Yes

No

Have you experiences any of these conditions? (check all that apply) *

Asthma

Acid Reflux (GERD)

Fibromyalgia

PMS

TMJ

Tinnitus

Allergies

Headaches/Migraines

Recurrent Ear Infections

Recurrent Sinus Infections

Immune Disorders

Genetic Diseases

Chronic Pain

Whiplash

ADHD

Autism

Anxiety

Panic Attacks

Depression

Sleep Issues

None of the above

How was your birth? *

Vaginal

C-Section

Natural (no pain medications)

Epidural

Vacuum

Long Labor

Quick Labor

Hospital

Home

Release of Liability *

I understand that the craniosacral therapy I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that craniosacral therapy should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a qualified medical specialist for any mental or physical ailment that I am aware of. I understand that craniosacral therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. Because craniosacral therapy should not be performed under certain medical conditions I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so. If I make any sexual advancements or innuendos the session will be terminated immediately without a refund. By submitting this form I affirm the accuracy of the information I have provided and understand and agree to the policies above.

I agree