Healing Client Intake

Bodywork & Healing Intake

Please complete this form to the best of your ability. Only the boxes marked with a red asterisk are required. Your information is held strictly confidential and your written permission is required to release any information to any other party.

Date*

Month / Day / Year

Full Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Birth Date*

MonthDayYear

Cell Number*

E-mail*

Confirmation Email

Emergency Contact*

Cell Number*

Occupation

Medications

Allergies

Vaccinations

History of Pathology

List your issues here. Physical or emotional.

What stimulus makes it worse?

Family history to the best of your knowledge.

Rate of Pain Today

Frequency - please select the most accurate

At what time of day?

Past Repeating Pattern? If so add a brief summary.

Have you ever been in an accident (automobile, work, falls, etc.) ?

List all related treatments received.

Were the treatments effective?

Do the duties required of your occupation affect you? Explain.

What activities and hobbies do you enjoy?

Please list exercise and stress reduction activities. Lifestyle Improvements. Explain.

Please provide your primary care physician's name and number. Also include Chiropractors, Acupuncturists, etc.

Please read the policies carefully and sign.

Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

I understand the Restorative Therapies Bodywork & Potentialize Healing is a energy healing service with the intent of providing high quality work and energy healing in a clinic setting or other agreed upon location that supports a therapeutic envioronment. Phone & Zoom are considered telehealth therapeutic environments.
I understand there is a 24 hour cancellation policy and I am subject to immediate full payment of the appointment if I cancel my appointment within 24 hours.
I understand my session will include a consultation with my therapist to ensure the most effective treatment.
I understand that my therapist or I may end the session at any time for any reason without full or partial refund.
If my session runs over the allotted time I understand and agree to pay additional fees.
I understand that no refunds are given at any time, however, all session time purchased will be fulfilled unless otherwise stated herein.
I understand that all scheduled sessions are paid at the time of appointment.

Client Agreement:

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the treatment may be adjusted to my level of comfort.

I further understand that Potentialize Healing should not be construed as a substitute for medical examination,diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware.

I understand that bodyworkers are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

Because bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly.

I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for full payment of the scheduled appointment.

I understand that my practitioner will make every possible attempt to recover to the fullest potential to any injury or structural dysfunction I've sustained.

I understand that I am not "getting rid of" any condition. I understand that Restorative Therapies Bodywork & Potentialize Healing cannot confirm or deny any diagnosis nor offering treatment specifics. I understand Restorative Therapies Bodywork & Potentialize Healing cannot make recommendations about treatments other than common sense guidelines. I understand these bodywork sessions do not replace medical treatments, therapy, or medications. I understand that Healing sessions are not constructed as practicing medicine, healing, or curing conditions. I understand that Restorative Therapies Bodywork & Potentialize Healing cannot promise specific results or claiming to perfom healings or cures.

I understand that this document may be amended at a future time.

I agree to hold Restorative Therapies Bodywork & Potentialize Healing and Joshua Magee faultless should my condition worsen or death occurs.

Understanding all of this, I give my full consent to receive care with Restorative Therapies Bodywork & Potentialize Healing.

By my electronic signature below, I agree to the Restorative Therapies Bodywork & Potentialize Healing policy and client agreement above.

Signature*

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