client intake formAll information shared is valued, appreciated and confidential. Name * First Name Last Name Email * Address/Location * Date of Birth * Emergency Contact - Name & Number * Current Occupation (and past if relevant) * Relationship Status * Describe any significant past history concerning your physical body. (Please include any accidents, medical intervention, medication, symptoms, toxin or drug exposure, if you have ever been unconscious) * Describe any significant past history concerning your mental and emotional life. (Please include any major life stresses, traumas or events, as well as any medications or mental & emotional symptoms) * How is your mental and emotional life presently? (Please include any current mental health challenges, diagnoses and medications) * Do you take any medication or supplements? * Do you smoke and/or consume alcohol? * Do you or have you used recreational drugs? * What type of practitioners and health care providers have you consulted in the past and how helpful have they been? * Who do you have on your health team presently and how long have you been seeing them? * Is there any other information that may be relevant to your care that has not been covered? * CONTRAINDICATIONS If you have any of the below conditions, please let me know so we can discuss your suitability for Spinal Energetics. - Severe mental health conditions (bi-polar, schizophrenia, psychosis) - Cardiovascular problems/history of heart disease - History of seizures or aneurysms - Severe Asthma - Hospitalisation for any psychiatric condition, emotional crisis or spiritual emergence within the last 3 years. - Recent surgery - Recent injuries or fractures - Heavy medications that alter brain chemistry - Diagnosed with severe PTSD - Any other medical, psychiatric or physical conditions that may impair or affect your ability to engage in activities involving intense physical and/or emotional release Do you have any of the above conditions? Yes No Thank you!
