Intake Form

Name

Phone

How did you hear about me?

What is your age?

Date of Birth?

Occupation

Please list your current health issues.

Past Health History: Please list major illnesses, injuries, hospitalizations and surgeries over the course of your life.

Are you taking any medications? Please list:

Are you currently in psychotherapy?

If not, have you worked with a psychotherapist in the past?

Please list other medical and alternative therapies you are currently receiving.

What would you like to get out of our working together? What are your goals for your healing?

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Alison Shaw NP, LMT, CEH with www.bodymindresourcing.org is not a doctor, or a psychotherapist. Any insight given on this website www.bodymindresourcing.org, in her private sessions, classes, materials, videos, articles, or opinions, which are based upon her experience, education, and research, is for educational purposes only. This is not to be taken as medical or psychotherapeutic advice.
While we believe the information published on our site to be accurate, we do not intend it to serve as a substitute for professional medical or psychotherapeutic advice or treatment. If you have questions or concerns regarding your physical or mental health or the health of your family, please seek assistance from a qualified health care provider. www.bodymindresourcing.org or Alison Shaw is NOT liable in any case. Consult your health care provider before using any health information we publish via our website, our E-Newsletter, or any of our other publications, videos, audios, classes, and or counseling sessions.
I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge. I will inform my health care provider and Alison Shaw NP, LMT, CEH if anything changes in my status during the course of our work together.
I understand that Alison Shaw NP, LMT, CEH is not a doctor or a psychotherapist and does not diagnose or treat physical or psychological illness. I understand that any insight given on her website www.bodymindresourcing.org, in her private sessions, classes, materials, videos, articles, which are based upon her experience, education, and research, is for health education and wellness counseling purposes only and is not a substitute for a medical or psychotherapeutic examination, diagnosis or treatment.
I understand that I am responsible for consulting my health care provider before receiving  any and all therapeutic modalities used in Bodymind Repatterning sessions or using any health information or advise I receive via www.bodymindresourcing.org, Alison Shaw’s E-Newsletter, or any of her other publications, videos, audios, classes, and or Bodymind Repatterning sessions.
I understand that if I chose to receive massage therapy, movement therapy or bodywork during the course of my Bodymind Repatterning sessions, I do so at my own risk.
I hereby hold harmless and indemnify Alison Shaw NP, LMT, CEH and Bodymind Repatterning from all claims and liability whatsoever.