Name
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First Name
Last Name
Email
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Birthday
MM
DD
YYYY
Phone
*
(###)
###
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What brings you to bodywork / energy work?
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Please share any major medical history with approximate dates.
*
(i.e. surgeries, physical/mental/emotional trauma, broken bones, chronic conditions)
What does your body endure regularly?
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(i.e. occupation, physical practice, leisure activities, sleep, self care)
Are you taking any medication?
(If yes, please list below)
Are you currently immunocompromised?
Are you currently pregnant or is there a possibility that you're pregnant?
*
Have you ever tested positive for COVID-19? If so, please describe any ongoing effects the virus has had on your body
(ex: cardiovascular, bruising, fatigue, respiratory, etc.)
Please check any/all conditions you are currently experiencing
Please feel free to use this space to add any relevant details that I should know.
(i.e. present symptoms, duration of symptoms, what makes them better/worse, quality of discomfort/sensation, previous bodywork or energy work experience, etc)
If you are neurodivergent (or even if you aren't) are there any aspects of the session or preferences that you want to communicate about specifically? (example: level of pressure, scents, use of oil, lighting, particular words or phrases to use or avoid?)
Would you like me to put table extenders on to make the table wider? (If you find that in past massages, you feel like you need to hold your hands or tuck them under you to keep them on the table, this might be of interest to you)
How did you come to find out about the practice?
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Instagram
Lex
Dance community
Google Search
Other
Queer Healers
Manhattan Alternative
My friend told me about you!
Is there anything else you would like me to know before working together?
