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Intake Form

Please complete the Intake and Discovery Questionnaire. Doing so will give you the personalized customization you want and help me exceed your expectations.

Click the button below to start.

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Question 1 of 21

What's your first name?

Question 2 of 21

What's your last name?

Question 3 of 21

Don't worry, we're not going to spam you.

Question 4 of 21

*

Question 5 of 21

 *

Question 6 of 21

Street Address

Question 7 of 21

City

Question 8 of 21

State

Question 9 of 21

How often do you receive body care (massage, bodywork, chiropractic, private yoga sessions, etc)?

Question 10 of 21

Why have you decided that now in the time to schedule? Are you in pain, experiencing stress, needing to feel like yourself again, etc.?

Question 11 of 21

Stress magnifies everything and it shows up physically, mentally and emotionally. How does stress (good or bad) effect you?

 

 
 
 

Question 12 of 21

Rate you physical stress/pain levelRate you physical stress/pain level. 

0- no pain, 10-so much pain I want to scream

A

0

B

1

C

2

D

3

E

4

F

5

G

6

H

7

I

8

J

9

K

10

Question 13 of 21

How Mental stressed or overwhelmed do you feel?

A

0

B

1

C

2

D

3

E

4

F

5

G

6

H

7

I

8

J

9

K

10

Question 14 of 21

What about your emotional stress levelWhat about your emotional stress level?

A

0

Question 15 of 21

Select the areas that you are feeling tension, discomfort, pain or soreness

A

Head

B

Neck & Shoulders

C

Upper Back

Question 16 of 21

Please Select any conditions that apply

Question 17 of 21

How would you love to feel and what difference will it make for you? Please Explain.

Question 18 of 21

What are your goals for your session?

Question 19 of 21

New Question

Agreement


I expect to receive an exceptional service that is centered around my goals, comfort and preferences. I understand Fidel will tailor my session based on my requests and information stated above or in person.I expect to receive an exceptional service that is centered around my goals, comfort and preferences. I understand Fidel will tailor my session based on my requests and information stated above or in person.

 

I _____, agree to notify Fidel immediately if I am uncomfortable, experience any pain or discomfort so that adjustments can be made. Otherwise, it will be assumed I am comfortable. Likewise, Fidel had the right to end the session at any time if he is uncomfortable with the client’s request.I _____, agree to notify Fidel immediately if I am uncomfortable, experience any pain or discomfort so that adjustments can be made. Otherwise, it will be assumed I am comfortable. Likewise, Fidel had the right to end the session at any time if he is uncomfortable with the client’s request.

 

I_____, agree to notify Fidel immediately if I am uncomfortable, experience any pain or discomfort so that adjustments can be made. Otherwise, it will be assumed I am comfortable. Likewise, Fidel had the right to end the session at any time if he is uncomfortable with the client’s request.

 

I _____, agree to give 24 hours advanced notice to cancel/reschedule your appointment. Missed appointments and appointments not canceled/rescheduled within 24 hours notice will be charged the value of their appointment.I _____, agree to give 24 hours advanced notice to cancel/reschedule your appointment. Missed appointments and appointments not canceled/rescheduled within 24 hours notice will be charged the value of their appointment.

 

 

Question 21 of 21

Do you Accept

A

Yes

B

No

Confirm and Submit