Community CranioSacral Session Booking and Intake

    Client Information

    First Name *

    Last Name *

    Preferred Name (if different)

    Street Address *

    City, State *

    Zip Code *

    Mailing Address (if different)

    Cell Phone *

    Email Address *

    Date of Birth (Month/Day/Year) *


    Gender Assigned at Birth *

    If different, current gender identity

    Session Preferences & Booking

    All CranioSacral Sessions are 80 minutes, $250 each.

    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:

    Physical pain relief
    Relaxation / stress relief
    Somato-Emotional Release work
    Other

    Physical Injuries & Issues

    List any significant past or current physical issues/injuries (up to 6).

    Injury/Issue

    Symptom

    Severity (1–5)

    Year first occurred

    Severity range over time

    Current Medical Diagnoses

    List any current medical diagnoses (up to 6, leave blank if none).

    Diagnosis

    Year Diagnosed

    Current Medications

    Yes, see belowNo / none

    If Yes, please list (up to 6):

    Medication Name

    Year Started

    Satisfaction (1–5)

    Side Effects & Severity (1–5)

    Surgical History

    List any surgeries / procedures (up to 6, leave blank if none).

    Surgery / Procedure

    Year

    Post-Surgery Recovery

    If still recovering from any surgery, describe current symptoms (up to 6).

    Surgery

    Current Symptom

    Severity (1–5)

    Year Began

    Final Health Information

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

    YesNo

    Did someone help you complete this form?

    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) *