Community CranioSacral Intake Form

Community CranioSacral Intake Form

Hi, It's Sonya. Thank you for choosing BodyGuides, Community Craniosacral and Integrative Bodywork. I am an Advanced CranioSacral Therapist (plus other bodywork tools). I am honored to serve you. Please fill and click "submit" for this form at least 24 hours before your first session so I can be sure to be prepared. Wear loose, comfortable clothing to your session, ideally no belts, bra, or jewelry on the table.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Please provide the name, phone, and email of your emergency contact.
    NamePhoneEmail 
  • Please list any diagnoses you have received, date of initial diagnosis, and current severity (Fully Recovered, Mild, Moderate, or Severe). Click the + sign to add more diagnoses.
    DiagnosisDate of OnsetCurrent Severity 
  • If you suspect having a diagnosis please list along with approximate date of initial onset, and current severity (Fully Recovered, Mild, Moderate, or Severe). Click the + sign to add more.
    Suspected DiagnosisDate of OnsetCurrent Severity 
  • Please list any medications you currently taking, date began, and any side effects. Click the + sign to add more medications.
    MedicationDate BeganAny Side Effects 
  • Please list, in order of importance, your main reasons for seeking Integrative Bodywork. Include approximate date issue began, and whether currently mild, moderate, or severe. Just click the + sign to add up to five main issues.
    IssueDate of OnsetCurrent Severity 
  • Please list any health issues not already listed, such as physical injuries, surgeries, or pain, date began, and whether currently resolved, mild, moderate, or severe. List any devices you may have such as a pacemaker, IUD, stent, etc. Click the + sign to add history.
    Issue/Device/etcDate BeganCurrent Severity 
  • List Here 
  • Community CranioSacral/BodyGuides Agreements

    By marking "I agree" you are consenting to an agreement with Sonya White, owner of Community CranioSacral and BodyGuides.
  • It is my choice whether I wear a mask or not. My vaccination/non-vaccination status will not be asked by Sonya White, and it is not required to be disclosed for Community CranioSacral. If I would like Sonya White to wear a mask during our session, I will ask while refraining from asking Sonya White's vaccination status. I agree that if I show signs of COVID 19, or if I know that I am currently positive and symptomatic for COVID 19; that I will wait 45 days after symptoms subside to schedule or attend a Community CranioSacral session.
  • We appreciate you taking the time to fill this form out. All information is strictly confidential. I look forward to supporting your health!