How did you hear about us?*

If referred by a friend, who may I thank?

Please indicate which of the following symptoms you have experienced within the last 6 months:*

Your Birth Process

Do you know of any stressful situation that may have been present for your mother and/or father at the time of your birth?*

Growth and Development:

Provide information about the above questions under Growth and Development.*

Have you had any major stress, trauma, or injuries as an adult?*

What recent surgeries or hospitalizations have you had?*

What sports, if any, did you play in school or as an adult? Were there any injuries as a result of these sports?*

Do you use alcohol, drugs, nicotine, etc.?*

Will you continue taking recreational drugs, alcohol, nicotine, or prescription drugs during your Spinal Flow treatments?*

How would you rate your current diet?*

In what position do you generally sleep?*

Where do you currently work and what do you do there?*

On a scale of 1-5, how happy are you with your life right now? 1-not at all, 5-extremely happy*

On a scale of 1-5, how stressed are you currently in your life? 1-not at all, 5-extremely stressed*

If you did not have any of the above issues, what activities would you be doing?*

What is your body telling you right now?*

Why are you coming to see me? What are you hoping to get out of this experience?*

Are you willing to participate regularly in the sessions, which may include multiple sessions per day and/or per week? Are there any challenges you may have to attending multiple sessions per day/per week?*

Anything else you want me to know?*

By signing this form, I agree and consent to the healing work. I understand that with any healing process and work on my body, my symptoms may worsen before they get better. I understand this care is designed to assist the body with healing by helping to remove stressors from the body. I understand that healing takes time and there is no quick immediate fix to my problem, and health is a process. I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment. I understand that health insurance does not cover the treatments. I may utilize a health savings account or flexible savings account, and I will do my due diligence and talk with my carrier about coverage. If for some reason the treatments are not covered, I will be prepared to cover the costs and not hold The Sacred Center of Healing liable if my account declines to pay. I will participate fully in my healing process and discuss any recommendations with the practitioner before deciding to cancel. I understand that we are working together on my healing journey, and I will be an active participant. I agree to the above by typing my name in the box below.*