Client Forms

Client History Form

Please Note: All client information is held in the strictest confidence is never disclosed or shared without your explicit consent.

Name *

First

Last

Nickname / Preferred Name

Email *

Today's Date *

Birthday

Occupation / Current School

Mailing Address

If I wanted to send you a gift, where would I send it? (I will not share your address or mail you advertisements.)

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Contact

Emergency Contact: *

First

Last

Relationship: *

Phone: *

Alternate Emergency Contact:

First

Last

Relationship:

Phone:

All questions are optional. They help me know you as you are today.

Important Background Information

What is the most important thing that I should know about you right now?

Personal Support Network

Briefly outline your personal support system as it looks today (i.e., family, friends, health care providers, groups, etc.)

Meditation & Mindfulness:

Any experience with meditation or mindfulness practices? How is this for you?

Prior Personal Work

What kinds of personal work (if any) have you participated in or done?

Physical Activity / Exercise / Movement Practice:

Please describe any movement practice, exercise or physical activity that is present in your life right now. How is this currently working for you?

Medication & Drugs:

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.

Please check all that apply to you.

This is particularly helpful information for clients I work with in-person as I may engage your body in touch or movement.

Addiction Recovery

Length of time in recovery & any additional details

Please list allergies or sensitivities below:

Asthma: Do you need an inhaler?

High Blood Pressure: Do you take medication?

Pregnancy: How far along?

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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1. Approximate Date:

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2. Approximate Date:

3.

3. Approximate Date:

4.

4. Approximate Date:

5.

5.Approximate Date:

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Approximate Date: (copy) (copy) (copy) (copy) (copy)

Final thoughts:

Tell me more...

What do you hope to receive from our work together? What is going on 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.

Captcha *

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Client History Form

Mailing Address

Emergency Contact

All questions are optional. They help me know you as you are today.

Medical Background & History

Surgeries, Chronic Conditions & Injuries

Final thoughts:

Tell me more...

Please note:

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Land And Labor Acknowledgement
contact | work together | about | blog | DONATE NOW! | client portal