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Name
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First
Last
[object Object]
Today's Date
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Email
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How did you hear about me?
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Phone
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Date of Birth
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Age
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Gender
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Male
Female
Other
Describe the problem(s) for which you seek help. Please include dates when each problem occured
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Past medical history (previous injuries, accidents, surgeries, etc. Please describe and include approximate dates
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List the medications (including over the counter) you are presently taking
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What daily activities are you finding difficult or are limited because of your above complaints
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Have you ever had this problem before, and if so when?
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What are your goals for this session(s)?
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Please list any other kind of healthcare professionals you are seeing for this/these problem(s)
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Please check any of the following feelings you have experienced in the last few months
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Overwelmed
Depressed
Hopeless
Easily irritated
Anxious
Sad
Grieving
Unable to grieve
Apprehensive
Agitated
Fearful
Impatient
Restless
Uncertainty
Angry
Nervous
Worried
Critized
Please mark the circle that best describes the level of stress for the below listings.
My family Stress is:
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None
Minimal
Moderate
Severe
My work stress is:
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None
Minimal
Moderate
Severe
My health stress is:
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None
Minimal
Moderate
Severe
My relationship stress is:
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None
Minimal
Moderate
Severe
My financial stress is:
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None
Minimal
Moderate
Severe
Other stress is:
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None
Minimal
Moderate
Severe
How much time do you have for yourself to relax and what do you do to relax, i.e. hobbies, meditation, etc
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Do you exercise? And if so, what kind and how often?
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How many hours a night do you sleep?
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Is your sleep restful? If not, please explain:
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Please list areas of pain and rate the pain from 1 to 10 according to the scale on the right
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Pain Scale
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1. Slight awareness of discomfort
2-3. Awereness of discomfort as an aggravation
4-6. Pain is strong but you are still functional.
7-9. Pain is so strong you are unable to function normally.
10. You feel like you need to go to the emergency room.
Anything else you want me to know?
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I understand that the above information will be kept in strict confidence and is provided to Michelle Ketcham of Mystic Jade Healing in order to receive the best possible care and service. I understand that the service Mystic Jade Healing provides is intended to enhance relaxation, increase communication within the areas of the body, and to educate me to possible energetic or emotional blocks that may create pain and disease. The sessions are non-invasive, safe, and objective. It utilizes the body's own innate intelligence to reestablish communication within itself.
I understand that the sessions Michelle of Mystic Jade Healing gives are not a substitute for medical treatment or medications. I am aware that Michelle does not diagnose illness or disease nor does Michelle prescribe medications.
Late Arrivals: your session may need to be shortened to accommodate other clients who have made appointments. You will be charged for a full session.
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I have completed this intake honestly and understand everything within it.
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I understand and agree
I have a question
Thank you so much for selecting me as your Practitioner. I look forward to meeting and working with you.
Michelle Ketcham, Certified BodyTalk Practitioner, Reiki Master, and BodyIntuitive Pracitioner
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Home
About Me
Services
Resources
Cortices Technique
BodyTalk System
BodyIntuitive
Tuning Fork Therapy
Reiki
What is Muscle Checking?
Blog
Forms
Contact
