New Client Intake Form Name * First Name Last Name Email * Pronouns * Occupation * What is the reason for your visit? * Date of Birth * MM DD YYYY Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### May I reach you via text for follow-ups? * Yes No Emergency Contact * First Name Last Name Emergency Contact Phone Number * (###) ### #### Have you had body or energy work before? * Yes No Preferred Pressure * Light Medium Deep Do you like communicating while receiving body work? Yes Minimally No Skin Conditions/Sensitivities/Allergies Please name any, especially if you have any to oils. Apricot oil is used for gua sha and cupping. Please list any recent injuries and surgeries with details and dates. Do you have a history or presence of cancer, diabetes, circulatory, heart or any other medical condition I should be aware of? Do you have any communicable diseases? Are you--or is there any chance you may be--pregnant? * Yes No Please list any current meditataions. Bodywork can treat a number of emotional and physical ailments. Please list anything you find to be relevant and would like to work on. I have reviewed the confirmation email that include policies. I have requested and received clarification on any policies I did not understand fully. Yes I hereby request and consent to body and energy work services performed by Joey Pham of Heavy Rest under the terms that I will be received with great care and compassion. All that is shared within the session will remain confidential, and will received with non-judgement, opennness, respect, and safety as healing is the top priority. * Yes I understand that I am responsible for payment of all fees for any services provided. * Yes Thank you!