Your Information
Personal Intake Form
Please complete this intake form and bring it to your first session. It accompanies the Welcome & Membership Agreement.
Your Information
Name Address City / State / Zip Code Phone Email AddressDOB Age
Occupation, or previous Occupation Job Tasks / Responsibilities Do you have a spiritual practice or community to support your emotional well-being and engagement socially?Social Status ☐ Single ☐ Married ☐ Divorced ☐ Widowed
Children Grandchildren
Recreational / Sport / Fitness / Avocational Activities / Do for YourselfAdditional Questions Regarding the Current Injury or Condition
What part(s) of your body is currently experiencing discomfort, pain, tension, or limitation?
Can you describe the quality of these sensations? (For example: constant or intermittent, sharp, dull, aching, burning, tingling, numb, spreading, or other.)
Which activities, positions, or circumstances aggravate these sensations?
(For example: sitting for extended periods, reaching, driving, specific movements, or emotional states.)
What have you found helps to ease or reduce these sensations?
(For example: rest, specific positioning, movement, ice/heat, medication, stretching, breathing practices, or other approaches.)
Is your normal sleep pattern affected by this experience?
☐ Yes ☐ No If yes: Trouble falling asleep? ☐ Yes ☐ No Trouble staying asleep? ☐ Yes ☐ No
How often do you wake during the night? How do you feel upon waking?Please describe the history of this area of focus or injury.
Include when and how it began, the circumstances at the time, and your emotional state during the onset or relevant events (for example: calm, frustrated, anxious, overwhelmed, or other).
Have you experienced any past injuries, surgeries, or significant events to the same area(s)?
Please list dates and details where known.
Which other modalities, practices, or approaches have been supportive to your healing or well-being in the past?
Creating Your New Future — Reflection
The following reflections invite you to become the observer of your own mind and body. True change begins when we become conscious of the unconscious thoughts, emotions, and habits that have shaped our current experience. Your responses will help us co-create a path from the familiar past to an elevated future.
How you think,
How you feel,
How you act
Creates your own unique personal reality
That forms your personality.
What is the primary challenge, condition, or pattern in your life (physical, emotional, mental, or relational) that you would like to change or heal?
What thoughts, emotions, behaviors, or habits do you notice yourself repeating that keep you connected to this challenge or old story?
If this challenge no longer existed and you were living as your new, healed, or elevated self, how would you think, act, and feel on a daily basis? What would your life, relationships, and interactions with the world look like?
What lesson or greater meaning might this challenge be offering you, and who do you choose to become as you move beyond it?
Which recurring thoughts, emotional reactions, or automatic behaviors do you recognize as keeping you connected to your current circumstances or ‘old self’?
On a typical day, which emotions do you experience most frequently? How do these emotions influence your energy levels and physical state?
(joy, happiness, compassion, gratitude, anxiety, anger, sadness, resentment, worry)
Describe in detail how your daily thoughts, actions, and feelings would differ if you were already living as this future, healed, or elevated version of yourself.
Can you integrate seamlessly?