New Client Registration

I ask all new clients to complete this questionnaire. This helps me to better understand your history and screen for any issues, and your answers also help in finding therapies and protocols which may be better suited for you.

Those with any communicable conditions which could potentially contaminate the treatment area may need to be rescheduled until such time as the condition is certified as cleared.

All information is kept strictly confidential and is used only as an intake tool for assessment prior to sessions. Please see my policies page for further information.

Name *

Email *

Phone

Do you have any current skin rashes or infections?YesNo

Have you had any surgical metal placed in your body, or have you had any prior injury resulting in metal being embedded in your body?YesNo

Have you been diagnosed with any of the Ehlers-Danlos syndromes, including hypermobile Ehlers-Danlos, or Chiari malformation?YesNo

Have you had any kidney disease or been diagnosed with kidney failure?YesNo

Have you been diagnosed as having epilepsy?YesNo

Do you have any history of blood clots, or are you taking blood thinners at this time?YesNo

Do you have a pacemaker or any other implantable medical device?YesNo

Have you received a COVID vaccination or booster within the past 3 months?YesNo

Do you have any history of cancer, or are you being treated for cancer at this time?YesNo

For women: Are you pregnant or believe you may be pregnant?YesNo

What type(s) of sessions are you interested in receiving?Auriculotherapy (digital)Reflexology, feetReflexology, feet and handsReflexology, earsReflexology lymphatic drainageReikiSkin treatments

Register