Let’s get started.

Interested in booking a session with me? Fill out my intake form.

Before we begin our first session we will have a consultation, where we will review your intake form submissions. Please let me know about your goals for the session, whether it be relaxation or therapeutic or a combination. Also please advise of any changes in health status, allergies, skin sensitivities, injuries, rashes, cuts, scrapes, or bruises.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Birthdate

YYYY

Occupation

Referred By?

What services are you interested in?

Orthopedic Massage

Thai Yoga

Reiki

Cranial Sacral

What are your goals for your session?

Do you get regular headaches?

Yes

Do you receive regular bodywork?

Yes

Have you had any recent injuries? What was your diagnosis?

Do you have allergies? Please explain.