"Therapy Intake Form - Jolene Kelley"

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Therapy Intake Form
Jolene Kelley, LMT #17693
407 NE 12
Avenue
th
Portland, Oregon 97232
503-319-9747 / jolene@jolenekelleylmt.com
Today’s Date: _____________
Name:   _ _____________________________________Phone:   _ ____________________   D OB:     _ ____________________  
Address:   _ ____________________________________   C ity:   _ ______________   S tate:   _ _________   Z ip:   _ _____________  
Email   A ddress:   _ ____________________________________Referred   b y:   _ _________________________   _ ___________  
 
           
Emergency   C ontact:   _ __________________________   P hone:   _ ____________________   R elationship:   _ ______________  
 
Please   r eview   t he   f ollowing   c onditions   a nd   c ircle:   “ Y”   i f   i t   a pplies   t o   y ou   o r   “ N”   i f   i t   d oesn’t   a pply   t o   y ou.     I f   y ou   c ircle   “ Y”  
please   d escribe   a pplicable   i nformation   i n   t he   s pace   p rovided   b elow.  
 
Y     N    
Do   y ou   f requently   s uffer   f rom   s tress?    
Y     N  
Do   y ou   h ave   P MS?  
 
Known   c ause(s)?   _ _______________________    
 
Explain:   _ ______________________________  
Y     N  
Do   y ou   h ave   d igestive   i ssues?    
 
 
Y     N  
Do   y ou   h ave   v aricose   v eins?  
 
 
 
Explain:   _ ______________________________  
 
Where?   _ ______________________________    
Y     N  
Do   y ou   h ave   d iabetes?    
 
Y     N  
Do   y ou   h ave   c ancer?  
 
Explain:   _ ______________________________  
 
Explain:   _ ______________________________    
Y     N  
Do   y ou   h ave   a ny   a llergies?  
 
 
Y     N  
Are   y ou   p regnant?  
 
Explain:   _ ______________________________  
 
How   f ar   a long?   _ ________________________    
Y     N  
Do   y ou   e xperience   f requent   h eadaches?  
Y     N  
Do   y ou   h ave   c hronic   p ain?    
 
 
 
Known   c ause?   _ _________________________  
Where?   _ ______________________________  
Y     N  
Do   y ou   h ave   n umbness/tingling?  
Y     N  
Are   y ou   t aking   a ny   m edications?  
 
 
Where?   _ ______________________________  
 
What?     _ _______________________________  
Y     N  
Do   y ou   s uffer   f rom   a rthritis?  
 
Y     N  
Do   y ou   s uffer   f rom   d epression?  
 
Where?   _ ______________________________    
 
Explain:   _ ______________________________  
Y     N  
Do   y ou   h ave   c hronic   f atigue?  
Y     N  
Do   y ou   h ave   a ny   e ating   d isorders?  
 
Explain:   _ ______________________________    
 
Explain:   _ ______________________________  
Y     N  
Do   y ou   h ave   c ardiac   o r   c irculatory   p roblems?  
 
Y     N  
Do   y ou   h ave   a ny   c ommunicable   d iseases?  
 
Explain:   _ ______________________________  
 
Explain:   _ ______________________________  
Y     N  
Do   y ou   h ave   h ormone   i mbalances?  
 
Other   C onditions/Comments:  
 
Explain:   _ ______________________________    
_____________________________________________  
Y     N  
Do   y ou   s uffer   f rom   e pilepsy   o r   s eizures?  
 
Explain:   _ ______________________________  
_____________________________________________  
 
 
 
Please   e xplain   y our   q uality   o f   s leep.     H ow   m any   h ours   o f   s leep   d o   y ou   a verage   n ightly?      
__________________________________________________________________________________________________
__________________________________________________________________________________________________  
1  
 
 
Turn   o ver    
Therapy Intake Form
Jolene Kelley, LMT #17693
407 NE 12
Avenue
th
Portland, Oregon 97232
503-319-9747 / jolene@jolenekelleylmt.com
Today’s Date: _____________
Name:   _ _____________________________________Phone:   _ ____________________   D OB:     _ ____________________  
Address:   _ ____________________________________   C ity:   _ ______________   S tate:   _ _________   Z ip:   _ _____________  
Email   A ddress:   _ ____________________________________Referred   b y:   _ _________________________   _ ___________  
 
           
Emergency   C ontact:   _ __________________________   P hone:   _ ____________________   R elationship:   _ ______________  
 
Please   r eview   t he   f ollowing   c onditions   a nd   c ircle:   “ Y”   i f   i t   a pplies   t o   y ou   o r   “ N”   i f   i t   d oesn’t   a pply   t o   y ou.     I f   y ou   c ircle   “ Y”  
please   d escribe   a pplicable   i nformation   i n   t he   s pace   p rovided   b elow.  
 
Y     N    
Do   y ou   f requently   s uffer   f rom   s tress?    
Y     N  
Do   y ou   h ave   P MS?  
 
Known   c ause(s)?   _ _______________________    
 
Explain:   _ ______________________________  
Y     N  
Do   y ou   h ave   d igestive   i ssues?    
 
 
Y     N  
Do   y ou   h ave   v aricose   v eins?  
 
 
 
Explain:   _ ______________________________  
 
Where?   _ ______________________________    
Y     N  
Do   y ou   h ave   d iabetes?    
 
Y     N  
Do   y ou   h ave   c ancer?  
 
Explain:   _ ______________________________  
 
Explain:   _ ______________________________    
Y     N  
Do   y ou   h ave   a ny   a llergies?  
 
 
Y     N  
Are   y ou   p regnant?  
 
Explain:   _ ______________________________  
 
How   f ar   a long?   _ ________________________    
Y     N  
Do   y ou   e xperience   f requent   h eadaches?  
Y     N  
Do   y ou   h ave   c hronic   p ain?    
 
 
 
Known   c ause?   _ _________________________  
Where?   _ ______________________________  
Y     N  
Do   y ou   h ave   n umbness/tingling?  
Y     N  
Are   y ou   t aking   a ny   m edications?  
 
 
Where?   _ ______________________________  
 
What?     _ _______________________________  
Y     N  
Do   y ou   s uffer   f rom   a rthritis?  
 
Y     N  
Do   y ou   s uffer   f rom   d epression?  
 
Where?   _ ______________________________    
 
Explain:   _ ______________________________  
Y     N  
Do   y ou   h ave   c hronic   f atigue?  
Y     N  
Do   y ou   h ave   a ny   e ating   d isorders?  
 
Explain:   _ ______________________________    
 
Explain:   _ ______________________________  
Y     N  
Do   y ou   h ave   c ardiac   o r   c irculatory   p roblems?  
 
Y     N  
Do   y ou   h ave   a ny   c ommunicable   d iseases?  
 
Explain:   _ ______________________________  
 
Explain:   _ ______________________________  
Y     N  
Do   y ou   h ave   h ormone   i mbalances?  
 
Other   C onditions/Comments:  
 
Explain:   _ ______________________________    
_____________________________________________  
Y     N  
Do   y ou   s uffer   f rom   e pilepsy   o r   s eizures?  
 
Explain:   _ ______________________________  
_____________________________________________  
 
 
 
Please   e xplain   y our   q uality   o f   s leep.     H ow   m any   h ours   o f   s leep   d o   y ou   a verage   n ightly?      
__________________________________________________________________________________________________
__________________________________________________________________________________________________  
1  
 
 
Turn   o ver    
Please   d escribe   w hat   a   t ypical   w eek   o f   e xercise   l ooks   l ike   f or   y ou.     D o   y ou   f eel   y ou   g et   e nough   e xercise?     Y     /     N  
__________________________________________________________________________________________________
__________________________________________________________________________________________________  
Please   e xplain   y our   e xperience   w ith   b odywork   a nd   o ther   h ealing   m odalities:   f requency   a nd   o ther   a pplicable  
information.  
__________________________________________________________________________________________________
__________________________________________________________________________________________________  
Please   l ist   r elevant   h ealth   i ssues,   i llnesses,   t raumas,   a ccidents,   f alls   o r   s urgeries   ( please   i nclude   d ates   i f   y ou   c an).  
__________________________________________________________________________________________________
__________________________________________________________________________________________________  
List   i n   o rder   y our   3   p rimary   g oals   o f   r eceiving   t reatment   t oday.  
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________  
 
(Initial)    
 
 
 
                                C lient   A greement  
_______I   u nderstand   t hat   t reatments   a re   g iven   f or   t he   w ell-­‐being   o f   m y   b ody   a nd   m ind   a nd   I   a gree   t o   c ommunicate  
with   J olene   i f   a t   a ny   t ime   I   f eel   l ike   m y   w ell-­‐being   i s   b eing   c ompromised.    
 
_______I   a ffirm   t hat   I   h ave   s tated   a ll   m y   k nown   m edical   c onditions   a bove   t o   t he   b est   o f   m y   k nowledge.      
 
_______I   a gree   t o   i nform   J olene   o f   c hanges   r elated   t o   m y   m edical   p rofile   a nd   u nderstand   t hat   t here   s hall   b e   n o   l iability  
on   J olene’s   b ehalf   s hould   I   f ail   t o   d o   s o.      
 
_______I   u nderstand   t hat   t reatments   a re   n on-­‐sexual   a nd   J olene   m ay   d iscontinue   t reatment   i f   t here   a re   a ny   s exual  
advances   o r   r emarks   a re   m ade.    
 
_______I   u nderstand   J olene   n ot   a   P sychotherapist   a nd   h er   i ntention   i s   t o   e ncourage   c lients   t o   e xpress   h ow   t hey   a re  
feeling,   i n   o rder   t o   s ee   h ow   p sychological   a nd   e motional   d isturbances   c ontribute   t o   p hysical   i mbalances   i n   t heir   b ody.  
 
_______I   a gree   t o   m ake   f ull   p ayment   t o   J olene   b y   t he   e nd   o f   e ach   t reatment.  
 
_______I   u nderstand   t hat   c ancellations   m ust   b e   m ade   4 8   h ours   i n   a dvance   a nd   I   w ill   b e   c harged   a   $ 55   c ancellation   f ee  
in   f ailure   t o   d o   s o.  
 
Your   s ignature   b elow   s ignifies   t hat   y ou   a gree   t o   u phold   t he   C lient   A greement.    
 
 
Client   S ignature:   _ ________________________________________________Date:   _ _____________________________  
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