Shirodhara - Intake Form

Date ___________________________________________

Name ____________________________________________________________________

Address___________________________________________________________________

Phone number _____________________________________________________________

Email address ______________________________________________________________

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Date of Birth ______________________________________________

Occupation ________________________________________________

What is the main reason you are here? (Ex: Stress relief? Curiosity? Healing?)

Is this your first shirodhara session?

Do you mind if you get oil in your hair?

How did you hear about me and these treatments?

This treatment traditionally uses copious amounts of pure oil. Shirodhara is a mild form of thermo-therapy. Consequently, the temperature of the oil is strictly monitored. Yet, it remains your responsibility to communicate any discomfort during treatment. Failure to do so waives all liability of Lisa Kathleen Tancredi or Turning Point Healing Arts.

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Lisa Kathleen Tancredi from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s),

It must be understood that this is considered integrative healthcare, and not a replacement for allopathic medicine. Everything that is said during the treatment will be heard with compassion and without judgment — and it will be held in strict confidence.

Any information exchanged during the treatment is educational in nature and is intended to help you become more conscious of your own health.

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Client’s Signature______________________________________________________________________

Date ___________________________________________________________

You agree to cancel 48 hours in advance or the full fee is expected.

Turning Point Healing Arts Center * 100B Danbury Road * Suite 101A * Ridgefield CT 06877

thefeelbettergroup.com. *  info@thefeelbettergroup.com * 203-417-0935