Thank you for scheduling a session!

Please take a moment to answer these questions:

You may fill these out with as much depth or as briefly as you like - if any questions are stressful, please skip them. Please reach out if any questions come up for you. Thank you!

Name (the name you'd like me to call you)

First Name

Last Name

Pronouns (example: she/her, they/them, he/him)

Phone

(###)

###

####

Birthday

Name and number of an emergency contact:

What is bringing you in for a session?

What are some things you enjoy doing these days?

Please share any current illnesses and stressors in your life. You may include medical history, surgeries, falls, concussions, etc..

Please share any information you know about your birth or if there were any stressors during pregnancy. This may not be something you know and it is okay to leave this blank.

Please list what other therapies or modalities you get support from (ex. mental health therapy, physical therapy, acupuncture, meditation, etc)

What are your intentions for your sessions? What would you most like to receive?

How did you learn of my practice?

Please share anything else you would like me to know before we meet:

COVID-19 Policy: Masks are optional during sessions. If you are wearing a mask, I will too. I typically also wear a mask during the hands-on portion of the session. I have a HEPA air filter running. Are there any other COVID considerations you would like me to take? Please let me know if you want me to test beforehand.

Please initial that you agree to: reschedule your session if you have COVID, flu or a cold, OR if you have had a covid exposure in the past 5 days.

Please initial you have received this information: As a licensed body worker in Vermont, the Office of Professional Regulation requires a public notice: My professional qualifications and training are posted in my "About" page on this website. The actions that constitute unprofessional conduct are outlined in 3 V.S.A. § 129a and 26 V.S.A. § 5427. If you have experienced any of these actions during an appointment with any bodywork practitioner registered in Vermont, you can file a complaint with the Office of Professional Regulation in the link below.

https://sos.vermont.gov/opr/complaints-conduct-discipline/

Please initial that you agree that: All services provided are intended for general wellness and relaxation, they are not a form of medical treatment. If I experience pain or discomfort, I will let the practitioner know. I release my practitioner from all liability for any unintended harm resulting from the services. I understand that I or my practitioner have a right to end the session anytime.

Please initial that you agree: Cancellation Policy: Please reschedule with as much notice as possible. No shows and sessions cancelled with less than 24 hours notice are billed for half of the rate. This rate may increase if this occurs frequently within a few months.. This fee is waived for COVID, illness, inclement weather, and emergencies.