Orofacial Session Booking and Intake -

First Name *
Last Name *
Preferred name if different than above
Street Address *
City, State *
Zip Code *
Mailing Address (if different than home)
Cell Phone *
Email Address *
Date of Birth (Month/Day/Year) *	DOB
Gender assigned at birth *
If you identify differently than birth assignment, what is your gender

All Orofacial Sessions are 80 minutes, $250 each.

Check all days of the week that are your preference for a session. For each day selected, choose your preferred times:

Day	Preferred Times (select all that apply)
Thursday	9am10:30am Noon1:30pm 3pm5:30pm 7pm
Friday	9am10:30am Noon1:30pm 3pm5:30pm 7pm
Saturday	9am10:30am Noon1:30pm 3pm5:30pm 7pm
Sunday	9am10:30am Noon1:30pm 3pm5:30pm 7pm

We'll text or email you to confirm and finalize the appointment.

I have received CranioSacral or other types of osteopathic techniques before.	YesNo
I have received energetic sessions before – for example, Reiki or sound healing.	YesNo

List orofacial issues/conditions and all related current symptoms, with severity, duration, and range (up to 6 entries).

Issue/Condition	Symptom	Severity (1–5)	Duration	Severity Range

List any current medical diagnoses and date/year of diagnosis (leave blank if none).

Diagnosis	Date/Year Diagnosed

List any non-orofacial issues that appeared after the orofacial problems, with symptoms, severity, duration, and range (up to 6).

Issue	Symptom	Severity (1–5)	Duration	Severity Range

Do you take any medications?

YesNo

If Yes, list (up to 6):

Medication Name	Date Began	Satisfaction (1–5)	Side Effects & Severity (1–5)

List any surgeries and date/year of surgery (leave blank if none).

Surgery / Procedure	Date/Year

If not fully recovered, list surgery, current symptoms, severity, duration, range (up to 4).

Surgery	Current Symptom	Severity (1–5)	Duration	Severity Range

List any significant physical injuries/issues not already discussed, with date first occurred.

Injury/Issue	Date First Occurred

For all unresolved issues – current symptoms, severity, duration, range:

Injury	Current Symptom	Severity (1–5)	Duration	Severity Range

Are you able to walk up a flight of stairs without assistance? *	YesNo
Client completed this form with assistance?	YesNo
If yes, Name of assistant

I agree to the Terms & Conditions and Privacy Policy, and consent to receiving communications regarding my appointment. *

Today's Date *	Date
Typed Full Name (Electronic Signature) * Example: /Jane Doe/