INTAKE FORM — Kaorin Marie

INTAKE FORM:

Please fill out the form with as much or as little information as you feel comfortable with. The information is to help us both orient to where you currently are, mentally, emotionally, and physically in order to prep for our bodywork/massage/integration session.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Have you received bodywork/massage before?

Yes

No

How did you find my work? - If someone referred you please list their name here.

How are you feeling in your body?

What areas of the body to you tend to hold stress/pain? Share whatever feels like it would be applicable for our session.

How are you feeling mentally/emotionally?

This is an open ended question for if there is desire to grant me a peak into your mental emotional space. Are there things you are currently working through and would like for me to bring support to during our session.

If you have recently been through an experience that you are looking to integrate feel free to share with me your experience.

Integration of large experiences could be related to a medicine/psychedelic journey, an immersive healing retreat, a vision quest, a near death experience, a traumatic experience etc.

Medical Conditions - Autoimmune conditions, cancer/cancer treatment, etc.

Please list any injuries - including concussions, bone breaks, muscle strains, surgeries, etc.

Anything else you feel is important to share with me.

Medications

Please share any medications you are currently on especially if you are looking for herbal care as well.

Graduated from the New Mexico School of Natural Therapeutics in August 2018.
Certified as a Natural Therapeutic Specialist & Massage Therapist & Bodyworker.