Intake & Consent Form

In Harmony BodyTalk Intake Form & Consent Form

Name: ___________________________________________________________________________________

Address: _________________________________________________________________________________

Phone Number: ______________________ Email: _______________________________________________

Birthdate: ___________ Birth Time: ________ Birth City & State: ____________________________________

Referred by: _______________________________________________________________________________

ABOUT YOU:

Gender: ____ Age: ______ Height: ________ Weight: _______ Marital Status: _________ Blood Type_____

Are you Pregnant? Yes ___ No ___ Unsure___ Due Date: _________________

Number, name & age of Children: _____________________________________________________________

Number, name, age & breed of Pets: ___________________________________________________________

People in your household: ___________________________________________________________________

How many hours per night do you sleep? ____________________________

Do you consider you sleep restful? Yes No

How often do you Exercise?

Every Day___ Every Other Day___ Approximately Twice a week___ Occasionally___ Rarely___ Never___

Occupation: _______________________ Employer: _________________________________

Emergency Contact: __________________ Emergency Contact Phone Number:______________________

Allergies & Allergic reactions:

Any existing Allergies? Yes___ No___ Unsure____

Any Drug/Medications Allergies? Yes___ No___ Unsure___

Tobacco/Alcohol/Caffeine Usage:

Alcohol: Never___ 1–4 drinks a month___ 1–2 drinks a day____ 3-4 drinks a day___ 5+ drinks a day____

Tobacco: Yes, I smoke daily___ Yes, I smoke occasionally____ I quit smoking/Years____ Never smoked____

Caffeine: I don’t use caffeine___ 1-4 a month___ 1-2 a day___ 3-4 Day___ 5+ day___

Issues & Symptoms

What issues, conditions or symptoms brought you here today?_______________________________________

____________________________________________________________________________________________________________________________________________________________________________________

When did this condition develop & how long ago did it start? _____________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is there anything that makes this condition worse? ________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What treatments are you currently using for this condition? ________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe the results you receive (Chiro, Physio, Massage, etc.) _______________________________________

List all current medications, over-the-counter, diabetic, dietary supplements and vitamins and their purposes:

List all operations and major illnesses and their approximate dates:

Pain & Physical Limitations

I am experiencing pain in the following areas (check all that apply):

Left Shoulder___ Head___ Right Shoulder___ Left Elbow___ Neck___ Right Elbow___ Left Wrist/Hand___

Right Wrist/Hand___ Back___ Left Hip___ Chest___ Right Hip___ Left Knee___ Abdomen___ Right Knee___

Left Ankle/Foot___ Groin/Genitals___ Right Ankle/Foot___

Availability:

Please list up to 5 dates/times you would be available to have a session done in-person. For distance sessions, you do not need to be available for the session but can indicate times where you will have a chance to relax, breathe and be fully present to read your session summary so I can plan to send it to you during one of these time slots.

____________________________________________________________________________________________________________________________________________________________________________________

Photo (for Distance sessions only)

Please attach a photo of yourself for your appointment (or Child, Pet or Business)

In Harmony BodyTalk Consent and Disclosure Statement: {2 pgs}

By submitting this form:

I understand that The BodyTalk System is a mind-body approach intended to enhance relaxation and increase communication between the mind and the body.

Any personal information provided to the BodyTalk Practitioner is confidential and may be shared with colleagues for learning purposes. The contents of my sessions will be held in confidence and will never be linked to me without my knowing and written consent or as required by law.

I know that the BodyTalk Practitioner at In Harmony BodyTalk & Tuning Forks is not medically licensed doctors and will not diagnose, treat, or prescribe for illness, injury, disease, or other pathological condition, or perform any act which constitutes the practice of medicine. I understand that the BodyTalk System is integrative with other healing modalities but not a substitute for medical treatment or medications.

I understand that during the next 24-48 hour period following the BodyTalk session, VMLD, Tuning Forks, Qi Gong & Reflexology the Body-Mind will be processing changes and shifts on all levels. Please consider drinking more water the next few days.

I understand participation in a BodyTalk session is voluntary and at any time I may choose to end my participation. In addition, BodyTalk entails light tapping and contact of energy points of the body. The BodyTalk Practitioner will inform me where tapping and/or contact (by the practitioner and/or myself) will occur, thus allowing for ongoing consent.

It is my responsibility to inform my BodyTalk Practitioner of any medical conditions or medications I am currently taking. I agree to keep the practitioner updated as to any changes in my medical profile. I understand that although I may seek information and counseling from my practitioner, my health and well-being or that of my child, pet and/or business is my own responsibility. It is my responsibility to consult my primary care provider, Veterinarian or to seek out other licensed medical help when necessary.

I understand that by providing this informed consent I am assuming full responsibility for my BodyTalk Session(s), Veltheim Method of Lymphatic Drainage, Tuning Fork Sessions, Qi Gong and Reflexology and I hold harmless both the BodyTalk Practitioner and location where the session is done.

Signature: _____________________________________________ Date: _______________________

Sessions Offered:

$70 BodyTalk; $70 (12TFS) 12 DNA Tuning Forks; $70 Linking Awareness Healing Journey

$20 Add on (12TFS) Tuning Forks to a BodyTalk Session $90 BodyTalk & Tuning Forks Session

$123.00 (2 hour) BodyTalk Session prior to (VMLD) Veltheim Method of Lymphatic Drainage (energetic)

Packages: 3 BodyTalk Sessions $175; 3 BodyTalk + Tuning Fork sessions $225

Travel rate: If you need me to come to you, travel time is billed by time,

equal to the current session rate (One hr) multiplied by the number of hours in-transit

I understand that remote sessions are equally effective as office visits and are charged the same as office visits. I consent to receive and pay for any and all remote sessions per the current standard rate.

I am aware that sessions generally run between 45 minutes to an hour depending on the issues being addressed and that the length of time has no bearing on the efficacy of a session.

I am aware that payment is expected at or before the time of services. Credit card, cash and email money transfers are accepted forms of payment for all sessions (distance or in-person).

I understand a 24-hour cancellation notice is expected & missed appointments will be charged at a rate of $45.

If I have any questions or concerns, I will address these promptly with my BodyTalk practitioner.

I authorize In Harmony BodyTalk & Tuning Forks to provide me (or the child/dependent/pet/business listed in this application) with BodyTalk Session(s), Veltheim Method of Lymphatic Drainage (VMLD) [Energetic], Tuning Fork Session(s), Linking Awareness Healing Journey and/or Reflexology.

Helpful Suggestions for Your Session

*Read all materials carefully and make note of any questions you wish to discuss.

*During your on-site session, you will be lying face up and fully clothed on a massage table. Please wear natural fiber clothing, like cotton. It is especially important that you reduce the amount of nylon, spandex, or metal (including underwire bras) you are wearing, where possible.

*For distance sessions, you will be notified what time your session will be completed - you can continue with your day or find a place to consciously sit and breathe. Please take notes of any changes or sensations you may feel during or after your sessions. You will receive notes on your session within 48 hours of your appointment.

*Please arrive early in order to enjoy the full time of your appointment. Late arrivals may result in your session being limited due to time constraints.

*Please give at least 24 hour notice when canceling an appointment or cancellation fees will apply.

Signature: _____________________________________________ Date: _______________________

Client Forms