NEW CLIENT INTAKE FORM Name * First Name Last Name Email * Phone (###) ### #### Location / Time Zone Are you currently taking any medications? If so please list all, including both prescriptions and OTC medicines, with daily dosages. Please also include medications you may not take daily but on an as needed basis. * Do you have any known health conditions? Have you been given any formal diagnosis for a health issue in the past or present? Are you currently taking any supplements? (Please list those you take daily and as needed) Please list any medications you took for an extended period of time but are no longer taking. Include number of years. Do you have any allergies? Any food sensitivities? Digestive Health Please indicate if you experience any of the following: acid reflux/gerd stomach upset bloating gas diarrhea constipation have a hernia ibs other digestive issue What did you eat for the last two days for breakfast, lunch, dinner and as snacks? What did you drink? Energetics Please indicate if you experience any of the following: dry skin, dry eyes or mouth excessive sweating cold hands and feet rashes or redness in the face sensitivity to cold sensitivity to heat sensitivity to wind tiredness + exhaustion excessive energy or racing thoughts Do you have any musculoskeletal issues or pain? History of broken bones or surgeries? Do you know any details about how you were born or your early infancy? (ie. were you born vaginally or by c-section, were you breast or bottle fed, were you born premature or had to be in a nicu) Are you familiar with the ACE questionnaire? If not, please see link below for discussion during a session. If you are familiar and comfortable sharing your score, please do so below. How many hours per day do you look at a screen? How are you currently sleeping? Is this typical of your sleep patterns? How is your dream-life? SCOPE OF PRACTICE, CONFIDENTIALITY + RELEASE SCOPE OF PRACTICE It is a great joy and honor to work with you and educate you about embodiment practices, yoga, herbs and other wellness practices that may improve the quality of your life. Please remember as wellness consultant, I do not diagnose, cure, treat or offer medical help. I am an educator and not a therapist or a medical professional. Our work together is not a replacement for medical or mental care. If you should decide to take any herbs or supplements that I provide information about, it is your responsibility to communicate with your primary care or mental health provider about all herbs or supplements you are taking. Herb drug interactions exist. CONFIDENTIALITY Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost importance. HIPAA regulations require all practitioners obtain a signed release from their client before taking any information about them. I give my permission to this practitioner take notes, including health history, medical and/or personal information. All information will remain private. RELEASE By checking and signing below I understand this modality is not a replacement for medical care and this practitioner is not a medical provider or Therapist. The practitioner does not diagnose medical illness, disease or other physical or mental conditions. As such, the practitioner does not prescribe medical treatment. I have stated all my known conditions and take it upon myself to keep the practitioner updated on my health. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which might incur as a result of participating in this service. I knowingly, voluntarily and expressly waive any claim I may have against Alicia Allison or Clover and Timothy/Willow Song Inc. for injury, illness or damages that I might sustain as a result of participating in this service. I have read and consent to all written above Please e-sign by typing your full name below. Thank you! * ACE (Adverse Childhood Experiences) Questionnaire link can be found here.