Intake Form Name * First Name Last Name Pronouns * Today's Date * MM DD YYYY Cell * (###) ### #### Email * Age * DOB * MM DD YYYY Desired goals for seeking Healing Services? * (Ex. Stress relief, Increase flexibility, Sleep better) How have you been feeling body wise lately? * Is this your first professional Bodywork Session? * Yes No If no, when was your last session? MM DD YYYY Preferred Pressure * Light Medium Deep Skin Conditions/Sensitivities Allergies/ Sensitivities to Oils (Please list anything you’re allergic to) Do you experience migraines or Headaches? How often? Describe any recent injuries Describe & date any surgeries Do you have a history or presence of cancer, diabetes, circulatory or heart conditions or any other medical condition I should be aware of? Do you have any communicable diseases? Are you — or is there any chance you may be — pregnant? Yes No Please list any current medications Are you under a doctor’s care? Yes No Emergency Contact Name * Emergency Contact Phone * (###) ### #### Is this a referral? If so, who? I always like to show gratitude Please feel free to share any further information you feel is relevant to your treatment. Agreements I have reviewed the confirmation text that include policies. I have requested & received clarification on any policies I did not understand fully. * Yes I hereby request and consent to Bodywork services performed by TuneInWithTristen.I understand that these services are intended as a complementary therapy and should in no way take the place of a doctor’s care when it is indicated. I understand that results are not guaranteed. * Yes I understand that information exchanged during any session is intended to be educational in nature and is to be used at my own discretion. * I understand As a client,I understand that I am responsible for payment of all fees for any services or products and there are no refunds. * I understand Any unused services may be gifted to someone else. I understand All prepaid services expire after 45 days. * I understand Thank you!