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Patient Intake Form
First name
(Required)
Last name
(Required)
Birthday
(Required)
Month
Month
Day
Year
What are your preferred pronouns?
Service Booked
(Required)
Choose one
If 'Other' describe below:
Preferred Practitioner (If none type 'None')
(Required)
How were you referred to Brain and Body Recess?
How are you feeling today? (Frozen, numb, drained, calm, aligned, etc?)
What do you hope accomplish during this session?
Do you have any medical conditions, sensitivities, and/or injuries we should know about?
(Required)
Do you take any medications? If 'yes' list below.
How many cups of water do you drink daily?
Do you actively practice meditation, breathwork, or stillness?
Preferred Session Environment
Silence
Gentle Talk
Music/Sound
Guided Breath
Touch Consent
(Required)
Yes, I'm fully comfortable with my therapist working anywhere they see fit.
No, I would like my therapist to avoid these areas:
List which bodily areas you would like your therapist to avoid during your session.
Do you have any spiritual or cultural needs?
Are you interested in any of the following service? Check all that apply:
Acupuncture
Chiropractic Care
Yoga Nidra /Breathwork
Yoga (Group/Private)
Coaching
Detox
Energy Healing
Other
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