Client History Form
Please Note: All client information is held in the strictest confidence is never disclosed or shared without your explicit consent.
If I wanted to send you a gift, where would I send it? (I will not share your address or mail you advertisements.)
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?
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?
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.
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.
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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.