New Client Intake Form
PLEASE FILL OUT THIS FORM IF YOU ARE A NEW CLIENT.
I WILL BE IN TOUCH WITHIN 48-HOURS TO SCHEDULE YOUR NEW CLIENT SESSION.

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First Name *
Last Name *
Email Address *
Phone Number *
Street Address *
City *
State *
Zipcode *
Country *
Age
Physician's name and phone number: *
Are you planning to request a superbill from us (for you to submit to your insurance to request reimbursement)? *
Do you have a treatment order from your physician for occupational therapy services? *
Are you currently working? *
What is your occupation? *
How did you hear about our services? *
What is the primary issue that motivated you to seek out services? *
What is your secondary complaint? *
When did your symptoms begin? *
How did your symptoms begin? For example, did they begin because of an accident or trauma, or did they begin without a known cause? *
What activities INCREASE your symptoms? *
What activities DECREASE your symptoms? *
List any other modalities or therapies you have tried for this condition and describe their effectiveness. *
Please list all your surgeries, traumas, accidents, or other conditions, and the years they occurred: *
Are you currently pregnant or is there a possibility you may be pregnant? *
Please list all current medications and supplements as well as dosage and reason for taking them: *
Please rate on a scale from 1-10 how much emotional stress your symptoms have caused you, with 1 being very little and 10 being the worst you can imagine. *
Required
List all your goals for treatment. Be as specific as possible: *
Please share anything else you think I need to know before we begin working together:
I require at least 24-hour notice for cancellation of a treatment session that is not due to an emergency, COVID symptoms, or other illness. By clicking "Yes, I Agree" below, you agree that if you cancel with less than 24-hour notice, for reasons other than the aforementioned, you will pay the full session price (or forfeit the session within a healing program). *
FOR IN-PERSON CLIENTS: By selecting "Yes, I Agree" below you agree to do your best to remember to: NOT apply lotions or oils to your body prior to/on the day of your appointments; and to wear comfortable undergarments (underwear, boxers, loose gym shorts, sports bra). Both of the above mentioned will greatly assist in a comfortable and effective myofascial release or self-myofascial release treatment. *
By selecting YES below you agree to having photographs of you taken for assessment and re-assessment purposes ONLY. These photos will not be shared with anyone and are stored in a password secure, HIPAA compliant computer file. Please note, although these photos are very helpful in aiding a targeted treatment plan, they are optional. You can select NO below if you do not consent. *
I understand that Sara (aka Jahara) Seitz is not licensed in the United States to diagnose medical conditions. I have been advised and agree that if I believe that I may suffer from a medical condition, I will consult a medical doctor immediately. I am aware that I am responsible for my own healing, health and well being. I understand that the practices and therapy provided by Sara (aka Jahara) Seitz are rooted in the holistic healing arts combining bodywork with contemporary bodymind psychology. Therefore, a therapeutic session can include touch, meditation, and client centered dialogue. I understand that no guarantee or promises of cures have or will be made to me and that any benefits which I experience come from within my own awareness and self-knowledge. Therefore, I agree to hold harmless Sara (aka Jahara) Seitz from any and all claims, lawsuits, costs, expenses, or liability of any kind for injury or damage resulting from negligence or other acts, arising from or relating to my education or participation in consultation with Sara (aka Jahara) Seitz.  I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF ALL CLAIMS AND LIABILITY AND A CONTRACT BETWEEN SARA (AKA JAHARA) SEITZ AND MYSELF.  BY CLICKING "I AGREE" BELOW AND BY COMPLETING THIS INTAKE FORM, I ACKNOWLEDGE THIS AGREEMENT.  I understand, as the client and/or above mentioned responsible party, that I am fully responsible for payment of all charges incurred. I understand that payment is due at the time of my appointment and that insurance is not accepted. Payment may be made by check, cash (with exact amount), or debit/credit card. *
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