Before your first visit

A gentle way to begin

This intake gathers the information I need before your first session. Share what feels comfortable. We can always talk through more in person.

This intake helps me prepare for your first visit. Share what feels true for you. We will go at your pace, and you can always add more in person.

Personal information

Full name

Date of birth

Phone number

Occupation (optional)

Referred by (optional)

Emergency contact and relationship

Emergency contact phone

Experience

Have you had CranioSacral Therapy before?

Any concerns about change in intracranial pressure?

Do you have Ehlers-Danlos?

What are your goals for treatment?

Current health

Reason for initial visit

Have you recently had an injury, surgery, or areas of inflammation?

If yes, please describe (optional if no)

List any known allergies

List any health concerns you have

Agreements

It is my choice to receive CranioSacral Therapy (CST) from Janelle Maxwell of MaxWell Massage. I am aware of the benefits and risks of CST and give my consent for care. I understand that there is no implied or stated guarantee of success or effectiveness of individual techniques or series of appointments. I acknowledge that CST is not a substitute for medical care, medical examination, or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that treatments may be covered by extended health care plans and give permission for MaxWell Massage and Janelle Maxwell to share necessary information with my insurance company when needed for payment.

I agree to the client agreement above.

I will participate fully as a member of my healthcare team. I will make sound choices regarding my session plan based on information from my CranioSacral therapist. I agree to participate in my own self-care and to communicate any time I feel my well-being is being compromised. I expect my practitioner to provide safe and effective treatment to the best of their skills and knowledge.

I agree to this contract for care.

Cancellations or rescheduling must be made more than 24 hours before the appointment to avoid paying for the session. If you or someone you live with becomes ill the day of your appointment, you will not be charged the full cancellation fee, but please try to provide as much notice as possible.

I understand the cancellation policy.

Typed signature (client name)

Legal guardian signature (if applicable)

I understand this form is not for emergencies and that submitting does not create a provider-client relationship until we confirm a session.

This form is not for emergencies. If you are in crisis, please call 988 or go to your nearest emergency room.

Prefer to book directly? Schedule online or send a message.

Questions first?

You do not need to complete this form to reach out. I am happy to answer questions anytime.

Contact me Book a Session