Client Intake Form Fill the Form Date First Name Middle Name Last Name Date of Birth Gender Male Female Marital Status Email Phone Number Address How did you find out about our services? What is the reason for seeking these services? What concerns do you have about your health and wellbeing? List in the order of priority Medical/surgical History – (symptoms, diagnosis, treatment, outcome) List any current medications or medications used in the past Family history of any significant health issues In case of emergency Name of a relative/friend Relationship Home Phone Disclaimer: Bioenergetic Sessions offered are complementary holistic approaches. I make no claim of these sessions being a replacement for any medical treatments. Clients receiving these sessions based on their own decisions. I certify that, I read and understand the above information. I will not hold the practitioner responsible for any errors or omissions that I have made in the completion of this form. I understand the service being provided is designed to be health aid and in no way to take the place of a doctor’s care when it is indicated. All client information is kept in strict confidence. I understand that the practitioner does not diagnose or treat any diagnosed condition and only corrects the imbalances of energy flows that are revealed during a session. I understand that my muscles will be checked manually for bioenergetic feed-back and I give permission to proceed with the session. Signature of the client/guardian if the client is under 18 Date Submit
