Kat Shea Healing Arts
(303) 447-0474
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CLIENT HEALTH HISTORY SUBMISSION FORM


Fields with * are required!

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Before naming all the problems, what brings you the most joy? *

Doctor/Chiropractor/Psychotherapist:

Current medications:

What are your goals in receiving massage therapy or body-mind psychotherapy?

Please name any conditions currently disrupting your life:

Head/Neck:

Spinal pain or limitations:

Muscles, joints of extremities:

Respiratory:

Digestive System/Abdominal Organs:

Nervous system:

Skin:

Endocrine, Reproductive:

Urinary:

Other:

If chronic pain is your concern, please list any other illnesses accidents, surgeries, or traumas you have experienced:

I confirm that the above information is true and complete to the best of my knowledge. I understand that this information and the details of my sessions with Kat Shea are confidential and will not be released without my written consent, unless required by law.

I understand I am responsible for payment upon receipt of service. Most health insurance does not cover Kat Shea’s services, but she will be happy to provide any receipts for me to submit to my insurance provider. In cases of Motor Vehicle Accident related Med Pay, which often does reimburse these services, I will make specific arrangements with both my own insurance company and Kat Shea.

I agree to provide a minimum of 24 hours notice when cancelling an appointment, or 50% of the session fee will apply.