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HOME > RESOURCES > FORMS > CRANIOSACRAL INTAKE FORM

CranioSacral Intake Form

I am requesting CranioSacral therapy for *

My family member
Myself

Name *

Name of family member *

Relationship to family member *

Age of family member *

Health concerns for family member *

Email *

Email

Confirm Email

Phone *

Preferred contact method (select all that apply) *

Email
Text
Phone call

Emergency contact *

First

Last

Emergency contact phone # *

Emergency contact relationship *

Other relationship

Referred by: *

Have you ever had a CranioSacral session before? *

No
Yes

Has your family member ever received CranioSacral therapy or energy work before? *

No
Yes

When was your last session?

Number of previous sessions (if known)

Do you have a particular area of concern? *

Are you sensitive to perfumes or fragrances? *

No
Yes
Depends on what it is.

Which perfumes or fragrances?

Would you like aromatherapy used during your sessions? *

Yes
No

Are you sensitive to touch? *

Yes
No

Explain any tactile sensitivites

Consent to treat with CranioSacral therapy *

I understand that CranioSacral therapy is a simple, gentle, hands-on energy technique that works with the subtle rhythm of the cerebrospinal fluid in the body and is used for stress reduction and relaxation. I understand that CranioSacral therapy practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that CranioSacral therapy does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that CranioSacral therapy can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

PRIVACY NOTICE: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.

Name *

First

Middle

Last

Today's date *

Message

*** For more information about CranioSacral and the method I use, check out the Heartwood Institute (which is informed by the Upledger CranioSacral methodology).***

Intake form
Covid-19 Waiver
HIPAA Notice
Informed Consent
Consent for Minors

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

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