Name *

Email address *

Date of Birth

Reason for Visit

Referred By

What do you like about your health?

What do you do to de-stress?

Please mark current or past symptoms.

Ear/Sinus Issues

Childhood

Adulthood

Both

Asthma

Childhood

Adulthood

Both

Sleep Issues

Childhood

Adulthood

Both

Vertigo

Childhood

Adulthood

Both

Anxiety

Childhood

Adulthood

Both

Depression

Childhood

Adulthood

Both

Mood Swings

Childhood

Adulthood

Both

ADD/ADHD

Childhood

Adulthood

Both

Headaches

Childhood

Adulthood

Both

Auto-immune issues

Childhood

Adulthood

Both

Seizures

Childhood

Adulthood

Both

TMJ

Childhood

Adulthood

Both

Other Symptoms

Please list history/age of any injuries, falls, chronic or recurring conditions or symptoms, and major life transitions/events, i.e., death of loved ones, divorce, illness, surgeries, accidents.

Describe what you know about your birth experience, i.e., was it natural, C-section, with epidural, Pitocin, anesthesia, extended labor, pre/post birth complications, medical interventions, extended hospital stay, adoption? Were you breastfed? Did your mother experience any chronic low-grade and/or major life stressors or events during gestation, birth, and/or during your first two years of life?

I understand that Craniosacral Therapy given is for the purpose of relaxation. I understand that the therapist does not diagnose illness, disease, or any other physical or mental disorder, nor do they prescribe medical treatment or pharmaceuticals, or perform spinal manipulations. It has been made clear to me that this therapy is not a substitute for medical examinations and/or diagnosis, and that it is recommended that I see a physician for any physical ailment(s) that I may have. I have stated all of my known medical conditions and agree to update my therapist as to any changes to my health. If I feel uncomfortable at any time during the session, it is my responsibility to notify the therapist, and if I request the treatment to cease, the therapist will end the session. *

I agree

Signature of Client, Parent or Guardian *

Clear

Cranio-Sacral Intake Form

Please mark current or past symptoms.

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