Pediatric Craniosacral Therapy/Myofascial Unwinding Client Intake Form

Family Medical History

Please indicate if any blood relatives to the child have had any of the following by using the notations: M = Mother MGM = Maternal Grandmother PGM = Paternal Grandmother F = Father MGF = Maternal Grandfather PGF = Paternal Grandfather S = Sibling

Pregnancy

Birthing Time and Birth (Labor and Delivery)

Birth Information

Nutrition

Vaccinations/Immunizations

Illnesses

Health Care Providers

General System Review

Please take a moment to carefully read the following information and sign where indicated. If your child has a specific medical condition or specific symptoms, massage/craniosacral therapy/Reiki may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that the massage/craniosacral therapy/Reiki that my child receives is provided for the basic purpose of relaxation and relief of muscular/connective tissue tension. If I notice that my child is experiencing any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my child’s level of comfort. I further understand that massage/craniosacral therapy/Reiki should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailments that I am aware of. I understand that massage/craniosacral therapy/Reiki practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/craniosacral therapy/Reiki should not be performed under certain medical conditions, I affirm that I have stated all my child’s known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my child’s medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so;

If I make any sexual advancements or innuendos the session will be terminated immediately without a refund.

I agree to give 48-Hour notice if I choose to reschedule or cancel an appointment for any reason other than a family emergency or sudden illness. If I cancel without 48-hour notice or do not show up to my appointment I agree to pay the full cost of the craniosacral therapy session.

By submitting this form I affirm the accuracy of the information I have provided and understand and agree to the policies above.

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