Pronouns

Age

Parent/guardian email

Mailing address

Referred by

Specifics on any of the above, including dates/timelines, if known:

Allergies, medications & supplements (current):

Any illness, injuries, surgeries, etc. (past or present), including dates & details, if known:

Birth details, if known:

Anything else you'd like to share:

Client Agreement

By signing below, I hereby authorize my child named above to receive craniosacral therapy and/or bodywork at YARROW. I am aware of the benefits and risks. I understand that there is no implied or stated guarantee of success or effectiveness of individual techniques or series of appointments. I acknowledge that these therapies are not a substitute for medical care, examination or diagnosis. On behalf of my child, I have stated all medical conditions that I am aware of and will inform the practitioner of any changes in their health status. I expect the practitioner to provide safe and effective treatment to the best of their skills and knowledge. I am responsible for all charges for all services provided. I understand the 24-hour cancellation policy and that I am responsible for the late cancellation fee if I do not provide 24 hours’ notice (or communicate in case of day-of illness/emergency). I hereby approve of future treatments, and I understand that I have the option to remain in the treatment room or to enter at will during the session. My typed name below acts as my electronic signature.

New Client (youth/baby) Intake Form