Therapy Intake Form And Client Agreement Page 2

Please   d escribe   w hat   a   t ypical   w eek   o f   e xercise   l ooks   l ike   f or   y ou.     D o   y ou   f eel   y ou   g et   e nough   e xercise?     Y     /     N  

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Please   e xplain   y our   e xperience   w ith   b odywork   a nd   o ther   h ealing   m odalities:   f requency   a nd   o ther   a pplicable  

information.  

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Please   l ist   r elevant   h ealth   i ssues,   i llnesses,   t raumas,   a ccidents,   f alls   o r   s urgeries   ( please   i nclude   d ates   i f   y ou   c an).  

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List   i n   o rder   y our   3   p rimary   g oals   o f   r eceiving   t reatment   t oday.  

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(Initial)    

 

 

 

                                C lient   A greement  

_______I   u nderstand   t hat   t reatments   a re   g iven   f or   t he   w ell-­‐being   o f   m y   b ody   a nd   m ind   a nd   I   a gree   t o   c ommunicate  

with   J olene   i f   a t   a ny   t ime   I   f eel   l ike   m y   w ell-­‐being   i s   b eing   c ompromised.    

 

_______I   a ffirm   t hat   I   h ave   s tated   a ll   m y   k nown   m edical   c onditions   a bove   t o   t he   b est   o f   m y   k nowledge.      

 

_______I   a gree   t o   i nform   J olene   o f   c hanges   r elated   t o   m y   m edical   p rofile   a nd   u nderstand   t hat   t here   s hall   b e   n o   l iability  

on   J olene’s   b ehalf   s hould   I   f ail   t o   d o   s o.      

 

_______I   u nderstand   t hat   t reatments   a re   n on-­‐sexual   a nd   J olene   m ay   d iscontinue   t reatment   i f   t here   a re   a ny   s exual  

advances   o r   r emarks   a re   m ade.    

 

_______I   u nderstand   J olene   n ot   a   P sychotherapist   a nd   h er   i ntention   i s   t o   e ncourage   c lients   t o   e xpress   h ow   t hey   a re  

feeling,   i n   o rder   t o   s ee   h ow   p sychological   a nd   e motional   d isturbances   c ontribute   t o   p hysical   i mbalances   i n   t heir   b ody.  

 

_______I   a gree   t o   m ake   f ull   p ayment   t o   J olene   b y   t he   e nd   o f   e ach   t reatment.  

 

_______I   u nderstand   t hat   c ancellations   m ust   b e   m ade   4 8   h ours   i n   a dvance   a nd   I   w ill   b e   c harged   a   $ 55   c ancellation   f ee  

in   f ailure   t o   d o   s o.  

 

Your   s ignature   b elow   s ignifies   t hat   y ou   a gree   t o   u phold   t he   C lient   A greement.    

 

 

Client   S ignature:   _ ________________________________________________Date:   _ _____________________________  

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