Autoimmune Session Booking and Intake

    Client Information

    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) *


    Gender Assigned at Birth *

    If you identify differently than birth assignment, what is your gender

    Session Preferences & Booking

    All Autoimmune Support Sessions are 80 minutes, $250 each.

    Sessions focus on nervous system regulation, stress release and gentle support for autoimmune patterns.

    Please select the days that work for you and choose your preferred times for each selected day:

    Day

    Preferred Times (select all that apply)

    Thursday

    9:00am10:30am
    Noon1:30pm
    3:00pm5:30pm
    7:00pm

    Friday

    9:00am10:30am
    Noon1:30pm
    3:00pm5:30pm
    7:00pm

    Saturday

    9:00am10:30am
    Noon1:30pm
    3:00pm5:30pm
    7:00pm

    Sunday

    9:00am10:30am
    Noon1:30pm
    3:00pm5:30pm
    7:00pm


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

    Prior Experience & Session Goals

    I have received CranioSacral or other types of osteopathic techniques before.

    YesNo

    I have received energetic sessions before (Reiki, Sound Healing, etc.).

    YesNo

    I booked this session mainly for:

    Reducing flare-up frequency / intensity
    Managing chronic fatigue & energy levels
    Decreasing autoimmune-related pain & inflammation
    Nervous system regulation & stress relief
    Other

    Autoimmune & Health History

    Please list your autoimmune diagnosis/diagnoses (if known) and year of diagnosis.

    Diagnosis / Condition

    Year Diagnosed

    Current Symptoms & Patterns

    List main current symptoms, average severity (1–5), typical duration of flares, and range of severity over time (up to 6).

    Symptom / Pattern

    Severity (1–5)

    Typical Flare Duration

    Severity Range Over Time

    Current Medications & Treatments

    Yes, see belowNo / none

    If Yes, please list (up to 6):

    Medication / Treatment

    Year Started

    Satisfaction (1–5)

    Side Effects & Severity (1–5)

    Triggers, Flare History & Lifestyle

    List known triggers, major flare onset dates, and any lifestyle factors you feel influence your condition.

    Known Triggers / Factors

    Notes / Frequency

    Final Health Information

    Are you able to walk up a flight of stairs without assistance? *

    YesNo

    Client completed this form with assistance?

    YesNo

    Name of person who assisted (if any)

    Please list any additional health issues that you may have, along with date of onset and severity level.


    Today's Date *


    Typed Full Name (Electronic Signature) *