Energy Kinesiology Intake Form

Energy Kinesiology

Intake Form
Name*

First NameLast Name
Date*

MonthDayYear
Date
School (if a child):
Grade:
Parents' names if a child:
Date of birth:*

MonthDayYear
Date
Anatomical gender: *
Gender-identity: *
Preferred pronouns:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:*
Please enter a valid phone number.
Work Phone Number:
Please enter a valid phone number.
Email:*
example@example.com
Referred by:*
How did you hear about us?*

Social Media (Facebook, Instagram, etc)Google SearchYelpNextdoorArlNow/Patch/etcOther
Other (name of family/friend, doctor, physician, group, etc. Put N/A if not applicable)*
Reason for coming in:*
Relevant history of above condition or complaint:*

Please select anything that might apply and select the second column for anything especially important:*

	Past	Present	Select if especially important	None/Not applicable
Accident prone
Allergies
Clumsy
Constipated
Daydreams excessively
Difficulty budgeting time
Difficulty concentrating
Difficulty focusing eyes
Difficulty following directions
Difficulty telling time
Dizziness/vertigo/balance problem
Fear of speaking in front of a group/public speaking
Feels tired or hyperactive after eating
Headaches
Impatient/restless
Impulisve
Inappropriate drowsiness
Lacks confidence
Letter/number reversal
Leaves projects incomplete
Lies
Mood swings
Over or under-active
Phobias/fears (see below for details)
Poor at sports or dancing
Poor spatial awareness
Poor hand/eye coordination
Poor organizational skills
Poor reading comprehension
Poor spelling
Rests head on arm while works
Short attention span
Slow in completing work
Speech difficulties
Stops in the middle of a game
Test or performance anxiety
Timid/Shy
Trouble remember directions
Trouble remembering left/right
Trouble remembering names
Trouble remember times tables

Details for fears/phobias (write N/A if not applicable):*
Other (explain):
Anything else we should know?
I understand that Kathie Guhl will be muscle-testing me (my child). I realize she is not a physician, psychologist, psychotherapist, marriage counselor, clinical social worker, massage therapist, physical therapist or clergyman. I also understand that she will not diagnose, prescribe or treat any ailment or condition; rather, she will exclusively use stress release techniques designed to remove energy blockages, which may or may not relieve my symptoms. I understand that if I have any specific physical, mental or emotional problem(s), I should consult a licensed health professional for any prescribed course of treatment. I further understand that Kathie Guhl will report any suspected active child or elder abuse or threatened suicide per law.
Signature (guardian if client is a minor):*

Clear
Date*

MonthDayYear
Date

Client Agreement
Please read and sign where applicable
I,first and last name, give permission for my Teal Center practitioner to take notes about me, including health history/medical and/or personal information I choose to disclose. I understand that this information will be kept strictly confidential.

I understand that, according to OSHA, massage and bodywork represents a MEDIUM RISK while Covid-19 exists. I acknowledge that social distancing during a bodywork session is not possible and I accept full responsibility for taking that risk.

I also understand:
1. That massage therapy and/or acupuncture
- is for the purpose of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow; and
- is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.
2. That the massage therapists and/or acupuncturists
- do not diagnose illness, disease or any other physical or mental disorder;
- do not prescribe medical treatment or pharmaceuticals; and
- do not perform any spinal manipulations.
3. I agree that any and all appointment times are reserved exclusively for me and that I am responsible to remember them and to pay for appointments that I miss, cancel, or reschedule with less than 24 hours notice.

If I need to reschedule due to illness or Covid exposure, I agree to contact The Teal Center as soon as possible. I authorize The Teal Center to charge my credit card on file for 50% of the full amount of any appointment missed, cancelled, or rescheduled with less than 24 hours notice.

I have stated all my known medical conditions and take it upon myself to keep the practitioner updated on my physical health.
Name:*

First NameLast Name
Signature:*

Clear
Date:*

MonthDayYear
Date

Policies
Welcome!

Thank you for choosing The Teal Center!

Please read and initial each of the following
Initials* Appointments missed, cancelled or rescheduled with less than 24 hours notice will be charged 50% of the session fee. To avoid being charged for a missed appointment, we invite you to send a friend or family member in your place. Also, if we can fill appointments that are missed, cancelled or rescheduled with less than 24 hours notice the client will not be charged. It is your responsibility to remember your appointments. Confirmation emails are sent 48 hours prior to the scheduled appointment.
blanks* The Teal Center and its practitioners abide by the ethical standards of practice by their respective certification boards (NCBTMB and NCCAOM). All shall refrain from any behavior that sexualizes or appears to sexualize the client/therapist relationship. If such behavior occurs at any time, therapists are to terminate the session; payment will be made in full by the client and Center reserves the right to prohibit the client from returning to The Teal Center.
blanks*If you have a cold or other contagious illness, please call us before your so we can check with your therapist to see if it is appropriate for you to come in.
blanks* In order to preserve a peaceful environment, we ask that you silence your cell phones while at The Teal Center.
blanks* Tips are appreciated but never expected. If you wish to leave a gratuity for your therapist we ask that you do so in cash or by check made directly to them. Gratuity is also made possible via the Venmo app for some therapists.
blanks* If you move or change numbers, it is your responsibility to inform us. This is important information so we can reach you in case of any emergency or any necessary and unforeseen scheduling changes.
blanks* The Teal Center does not submit insurance claims. We are happy to provide you with medical receipts, any treatment notes and payment history for your personal records. We will communicate directly with your insurer at their request only.
Should be Empty:

Energy Kinesiology

Client Agreement

Policies