Full Name

Date of Birth (MM/DD/YYYY)

Phone

Email

Emergency Contact Name

Emergency Contact Phone

Health History — the following helps Jillian provide safe, effective care. It is kept confidential.

to Emergency Contact

Current Medications

List any medications you are currently taking, or write “None”.

Allergies

Include any allergies to oils, lotions, or latex, or write “None”.

Are you currently pregnant?

Health Conditions (check all that apply)

Areas of Pain, Injury, or Tension

Areas to Avoid

Reason for Visit / Goals for This Session

Consent & Agreement

Signature (Type Your Full Legal Name)

Date (MM/DD/YYYY)

New Client Intake Form