Client History Form
Please Note: All client information is held in the strictest confidence is never disclosed or shared without your explicit consent. Your email is added to Artemisia’s client list for occasional newsletters.
All questions are optional. They help me know you as you are today.
What is the most important thing that I should know about you right now?
Briefly outline your personal support system as it looks today (i.e., family, friends, health care providers, groups, etc.)
Any experience with meditation or mindfulness practices? How is this for you?
How do faith, religion, or spirituality show up in your life (if at all)? How do you refer to this? Is there any particular language you would like me to use or refrain from using?
What kinds of personal work (if any) have you participated in or done?
Please describe any movement practice, exercise or physical activity that is present in your life right now. How is this currently working for you?
Do you have any conditions that will affect or be affected by touch or moving your body or is there anything you would like me to know about your experience or needs around touch?
Are you taking any prescription/non-prescription medication or recreational drugs? If so, for what reason?
Medical Background & History
All questions answered below will help me work more effectively with you.
This is particularly helpful information for clients I work with in-person as I may engage your body in touch or movement (especially Phoenix Rising Yoga Therapy clients.)
Surgeries, Chronic Conditions & Injuries
Please list any history of surgeries, major illness, chronic conditions, accidents, injuries, or anything that might be relevant while working with you.Our work together may touch on all aspects of you as an emotional, psychological and physical being. Knowing what your body has being through can be quite helpful.
You always get to be in choice and may change your mind for or against any of these tools at any time.
What do you hope to receive from our work together? What is going on with you in your life right now that inspired you to use a mind-body alternative healing modality? Is there anything else you’d like me to know?:
Please note:artemisia shine is not a licensed physician/mental health clinician.
The alternative healing services provided by artemisia shine are not licensed by the state of California nor are they a substitute for licensed medical care.