Intake Form

Please complete if you have any of the following Conditions/Issues:

First Name

Last Name

Email Address

Sleep Disturbance, Skin, Digestion, Muscles/Joints, Cardiovascular, Repiratory, Nervous System, Urinary, Diet/Chemical Dependency, Mental/Emotional, Men's/Women's Issues

Please describe major sources of stress in your life.

Please describe your major health (physical, mental, emotional, or spiritual) concern.

Please describe your desired outcome for your BodyTalk sessions.e your major health (physical, mental, emotional, or spiritual) concern.

Initials

Today's Date

By initialing and checking this box, I understand that the BodyTalk System is a mind-body approach provided by Tonya Moist, CBP, and is intended to enhance relaxation and increase communication within the areas of the body, and educate me to possible energetic or emotional blocks that may contribute to pain and disease. I understand that the BodyTalk System is not a substitute for medical treatment or medications. I am aware that the BodyTalk Practitioner does not diagnose illness or disease, nor does the Practitioner prescribe medications. I understand that my participation in a BodyTalk session is voluntary and that at all times I may choose to end my participation. In addition, BodyTalk entails light tapping and touching of energy points on the body. The BodyTalk Practitioner will inform me where touching and/or tapping by the practitioner and/or myself will occur, thus allowing for my ongoing consent. I understand that information exchanged during a session is educational in nature and is to be used at my own discretion. I also under- stand that any information imparted during these sessions is confidential and will not be released without my prior written consent, except as required by law. I agree to pay a $85 fee per session. Payment is due at the time of service. Since time has been especially reserved for me, I understand that a 24 hour cancellation notice is expected and missed appointments will be charged. I agree that providing this informed consent I am assuming full responsibility for my BodyTalk session and that I hold harmless both the BodyTalk Practitioner and the facility/location where the session is provided.

Thanks for submitting!