Origin Forces

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PRIVATE SESSION

We offer private sessions for adults, children, parents and infants. Each session is customized to the client's personal needs, and is held in confidence and safety.

Please fill out the form below and submit. You can expect our response via e-mail. For following visits you can simply use the "schedule visit" button.

A. ADULT INTAKE FORM B. INFANT AND CHILD INTAKE FORM

Adult Intake Form

The first session will be 90 minutes in length.

Wear comfortable clothes

After your session- take time to write in a journal, color, or take a walk to integrate and digest.

Name:	*
Phone	*
Address	*
City	*
State	*
Zip	*
In case of emergency, contact
Phone	*
Surgeries (date each of them, starting with the most recent)
Head injuries (date each of them, starting with the most recent)
Dental work? (Braces, surgeries)

What other medical, psychological, manual doctors or therapist are you seeing?

Sometimes it is helpful for me to confer with your other therapist (doctors), so we can be on the same page with your needs, and updated with your progress. Is this OK with you?	Yes No
Have you ever had bodywork before? If so, what kind(s)?
What do you hope to gain from our sessions together?
Hospital/ Home?
Who was present for the delivery?

Early/ on time/ late?
Vaginal/ c-section/ breech?
Forceps/ Vacuum extraction?
Episiotomy?	Yes No
Medications or other interventions?
Do you know if your mother felt supported during pregnancy?
Were you breast feed?	Yes No
(for about how long?)

INFANT AND CHILD INTAKE FORM

Mothers, for your child's first appointment you will need to:

Fill out intake form

Schedule a phone appointment to review the intake and prepare for the session with Elizabeth, 25 minutes

Schedule your child's session. Both parents and grandparents are welcome. Just one parent is also completely Ok. First session will be 90 minutes.

And lastly schedule a follow up phone call, 25 minutes

All three appointment's are included in the fee

Child's Name
Birth Date
Mom
Phone
Dad
Phone
Address
City
State
Zip
In case of emergency, contact


Conception
Was conception natural, in vertro, or other?

Planned or a surprise?

If conception was a surprise at what point was your pregnancy welcomed by you and you partner?

Married/ single parent/ other arrangement?

Did you feel supported during your pregnancy?

Did you drink or smoke while pregnant?


Birth
How was birth initiated?

Was your baby early/ on time/ late?

Home birth/ Hospital?

Who was present for the birth?

Did you feel supported during birth? What was the most supportive part? Who was the most supportive person?

Vaginal/ c-section/ breech?

Forceps/ Vacuum extraction?

Episiotomy?
Yes No
Were there any other interventions?

Did you use medications?

What was your baby's Apgar score?

How long after birth was your baby able to breast feed?

How long did you breast feed?

Did you use a formula? (what one?)

Anything else you want to say about your or the baby's experience during birth?

What are your concerns with your child now?

What do you hope to accomplish with this work?

CREDIT \| Origin Forces © 2007