CranioSacral Therapy Intake FormPlease complete this required form before your session as thoroughly as possible. The information provided is kept confidential. Date MM DD YYYY Name * First Name Last Name Height Weight Date of Birth MM DD YYYY Address (street, city, state, zip) Home Phone (###) ### #### Cell Phone (###) ### #### Work Phone (###) ### #### Email Occupation How did you hear about us? Name of Family Physician When was your last check up? Results of last check up Have your ever received a professional CranioSacral Therapay before? No Yes If yes, when? Purpose of your visit to address symptoms of PTSD or other Trauma? to relieve migraines or stress related disorders? relief for dental work/procedures? to address specific health concerns? If purpose of visit is to address specific health concerns, please specify Do you experience headaches often? If so, please describe Briefly detail any trauma event in your life: death, accidents, attacks, etc. Any serious falls or injuries? If so, when Any surgeries? If so, when Any spinal problems? If so, please describe Are you pregnant? If so, how many weeks? Complications? If you are taking any prescribed medications, please list Are you involved in sports or exercise on a regular basis? Any other physical or mental conditions to be aware of before proceeding with a CranioSacral Therapy session? If so, please describe * I understand that the CranioSacral therapist does not diagnose illness, disease, or any other physical or mental disorder, nor do they prescribe medical treatment or pharmaceuticals. * I understand that CranioSacral therapy is considered to be a contradiction for recent injuries to the neck and head such as recent whiplash or fracture near the base of the neck, concussions or hemorrhages. Currently, I am not experienceing any of these conditions. * I understand that CranioSacral therapy is not a substitute for medical examinations and/or diagnosis for any physical ailment that I might have. * I understand that it is necessary for the CranioSacral therapist to be aware of any existing physical conditions. I have stated above all my known medical conditions and intend to keep the CranioSacral therapist updated on my physical health for future sessions. I release the therapist from responsibility and liability for any adverse reactions resulting from the disclosed and undisclosed physical conditions. I have accurately completed the above information and have read it, understand it, and take responsibility for the answers and statements listed above Signature * Thank you!