Wise Owl Wellness New Client Intake Form
This form helps us tailor your experience to your specific needs and preferences. All responses will be kept confidential and are for professional use only. If you have any questions, please contact Kristy Harvey, Owner of Wise Owl Wellness, LLC at wiseowlwellnessaz@gmail.com or text 520-519-9083.
Sign in to Google to save your progress. Learn more
What is your first and last name? *
What are your preferred pronouns? *
What is your date of birth? *
MM
/
DD
/
YYYY
What is your address?
What is your phone number?
What is your email address? *
How did you hear about Wise Owl Wellness?
Clear selection
If you were referred by someone, please list their name so we can thank them.
Please list an Emergency Contact name and phone number.
What is the main reason you are requesting an appointment? *
How often do you exercise for at least 30 minutes at a time? *
How many hours do you sleep each night on average? *
Do you feel rested when you wake in the morning? *
What are sources of stress in your life? *
What are sources of comfort in your life? *
What experience have you had with the following:
No Experience
Tried It Once
A Few Times
I Practice or Receive Regularly
Yoga
Meditation
Therapeutic Dance
Thai Massage / Assisted Stretching
Cranial Sacral Therapy
Reiki
Clear selection
During my session, I would like to receive: (check all that apply) *
Required
What are your goals or expectations for our session together? *
What benefits are you looking for? Check all that apply. *
Required
For Thai Massage / Bodywork Appointments, what areas of the body would you like to focus on during your session? Check all that apply. *
Required
For Thai Massage / Bodywork Appointments, what areas of the body would you like to AVOID being touched? *
Required
For Gentle Touch (Cranial Sacral, Reiki) Appointments please check all that apply: *
Required
Are you currently experiencing any of the following conditions? Check all that apply *
Required
COVID-19. Please check any that apply. *
Required
On a Scale of 1 - 10, please rate your overall health. *
Poor
Excellent
On a Scale of 1 - 10, please rate your current stress level. *
Not Stressed
VERY Stressed
On a Scale of 1 - 10, please rate your current physical fitness level. *
Poor
Excellent
On a Scale of 1 - 10, please rate your current quality of nutrition. *
Poor
Excellent
Please list any medications you are currently taking. Type N/A if you are not taking any medications. *
Is there anything else you'd like us to know?
WAIVER: 
I hereby agree to the following:
 
1. That I am participating in a class/treatment/body work/massage that may require some physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.
 
2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in this experience. I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in the class.
 
3. In consideration of being permitted to participate in the class/massage session/body work, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program.
 
4. In further consideration of being permitted to participate in the class, I knowingly, voluntarily and expressly waive any claim I may have against the provider, Kristy Harvey, Wise Owl Wellness, LLC and affiliates, the studio/location and class/workshop sponsor, for any injury or damages that I may sustain as a result of participating in the program/session.
  
I have read the above release and waiver of liability and fully understand its contents.  I voluntarily agree to the terms and conditions stated above.
 *
Signature. Please type your full name. *
Today's Date *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms