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SELF CARE SLIDING SCALE
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INTAKE FORM
WAIVER FORM
Your Body's Story - Intake Form
Today's Date
*
Month
Day
Year
First name
*
Last name
*
Birthday
*
Month
Month
Day
Year
Email
*
Phone
*
Emergency Contact (Name + Relationship + Phone)
*
What are your intentions or goals for our time together?
*
Do you have any of the following? Please check all that apply
*
High Blood Pressure
Low Blood Pressure
Recent Surgery / Joint Replacement
Chronic Pain
Anxiety / Depression
Insomnia
PTSD
Pregnancy
Headaches
None Of The Above
Other
Additional information you would like to share.
*
Submit
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