Client Intake FormPlease fill out this form prior to scheduling an appointment together! Thank you so much Name * First Name Last Name Phone (###) ### #### Email * Date of Birth MM DD YYYY Address Emergency Contact Name and Phone Number First Name Last Name Referred By? What services are you interested in? 1-1 Aquatic Bodywork 1 HR Couples Aquatic Bodywork Experience and Instruction 3 HRS Pool Movement 1 HR What is the main reason for your visit? * Have you ever had Aquatic Bodywork/ Watsu before? If yes, please describe. Please list any health concerns you may have or are currently being treated for? Do you see any other practitioners for this issue? Have you had any surgeries? What were the surgeries and approximate dates? How comfortable are you in water? Have you had any traumas associated with water? Do you do any type of regular exercise? If so, please describe. Do you have any current pain or discomfort? Open wounds/rashes/skin conditions Diabetes Seizures Any heart/circulatory condition Any respiratory/lung condition High/low blood pressure Ear problems Any loss of sensation/numbness Any infectious disease Chlorine sensitivity Heat sensitivity Dizziness or motion sickness Traumatic Brain Injury/Concussion Traumatic Vehicle Accident PTSD Are you prone to motion sickness? Yes No Are you sensitive to water in your ears? Yes No Do you have certain movements or activities that are limited? Please explain. Are there any movements or positions that increase your symptoms? Are there any movements or positions that decrease your symptoms? Is there any part of your body that is sensitive to touch, massage, or stretching? What is your pressure preference? Light Medium Firm Is there anything else you would like to share about yourself, your condition, your specific problems or needs? Terms & Conditions * *Feel free to wiggle or adjust your head and neck as needed, so you are in the best possible position at all times. If you are uncomfortable anytime, tell your practitioner so that your position can be adjusted. If you feel any motion sickness, tell you practitioner immediately so the session can be adjusted accordingly. If you wish to stop the session for any reason, please tell the practitioner. - I understand that Aquatic Bodywork/Watsu is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow. - If I experience pain or discomfort during the session, I will immediately inform my practitioner so that the session can be adjusted to my level of comfort. I will not hold my practitioner responsible for any pain or discomfort I experience during or after the session. - I understand that the services offered are not a substitute for medical care. I understand that my practitioner is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. - I affirm that I have notified my practitioner of all known medical conditions and injuries. - I agree to inform the practitioner of any changes in my health and medical condition. I understand that there shall be no liability on the practitioner’s part should I forget to do so. - I understand that Aquatic Bodywork/Watsu is entirely therapeutic and non-sexual in nature. - I understand that Aquatic Bodywork/Watsu is intimate in nature, with the therapist holding the client at points in close body to body contact. If this is triggering or uncomfortable, I agree to tell the Aquatic Bodywork practitioner in order to adjust the level of intimacy to my comfort level. - By signing this release, I hereby waive and release my Aquatic Bodywork/Watsu practitioner from any and all liability, past, present, and future relating to Aquatic Bodywork/Watsu. - Cancellations and full refunds are allowed within 24 hours of booking your appointment. I have read and agree to the terms above Thank you!
