Client Intake

Please complete this before your first session. It takes about 10 minutes and helps me tailor the work to your body.

What to Expect

Rapid Release works through your nervous system to bring your body out of its chronic alarm state. A few things worth knowing before we begin:

This is active work. Some movements are calm and releasing; others ask for real effort. Both matter.
Emotional and physical release is normal. As long-held patterns let go, you may notice sweating, changed breathing, vivid dreams, or flashes of memory, sensation, or emotion. This is expected. If anything ever feels overwhelming, tell me — and seek professional support if you need it.
I use a range of language. To describe what's happening in your body I may draw on anatomy, breath, energy, or consciousness. You don't have to connect with every word — the ideas work regardless of vocabulary.
Your role is communication. This work is about learning to listen and respond to your body with patience and compassion.

Client Information

First Name * Last Name * Date of Birth * Today's Date Email Primary Phone Alternate Phone Sex

Street Address

City State Zip

Occupation / Job Title Employer / Organization Years in Role Predominant Work Posture How did you hear about us? Referred by (name)

Emergency Contact

Name Relationship Phone Alternate Phone

Previous Care & Experience

If yes to any — describe what you tried and whether it helped:

Medical History

This helps me adapt the work to your body safely.

Currently under a physician's care for any condition?

Physician / Provider Name Specialty Phone Date of Last Visit

Known diagnoses & conditions (tap all that apply)

Other diagnoses or conditions not listed: Current medications, supplements, or injections (include dosage if known): Known allergies or sensitivities: Significant injuries (approx. year + body region): Surgeries (approx. year, type, body region): Screening

Notes on any 'Yes' answers above:

Chief Complaint

Primary reason for seeking care — in your own words: Pain level at rest

0 — none10 — worst imaginable

Pain level with activity

0 — none10 — worst imaginable

How long have you had this issue? Onset

What makes it BETTER? What makes it WORSE? What treatments have you tried for this specific issue? What helped, what didn't?

Pain & Symptom Map

Pick a marker, then tap where you feel it. Tap a marker again to remove it.

Additional pain / symptom notes:

Lifestyle

Average hours of sleep per night

Sleep quality

1 — poor10 — excellent

Daily average stress level

1 — low10 — very high

Estimated daily steps Hours seated per day

Do you exercise regularly?

Type of exercise / activity Frequency (days/week) Duration (avg min) Intensity (1–10)

Sports, recreational activities, or physical hobbies:

Do you practice meditation, breathwork, or mindfulness?

If yes — type / frequency:

Water intake per day Diet style (if specific) Caffeine intake Alcohol (drinks/week) Do you smoke / vape?

Goals & Expectations

Primary goal for this program? What would a successful outcome look and feel like to you? Commitment level

1 — low10 — all-in

Sessions per week you can realistically commit to Preferred session time

Body Awareness & Grounding

How connected do you feel to your body day to day?

1 — disconnected10 — fully in tune

Do you notice where you hold tension? If yes — where? Have you experienced significant emotional or physical trauma that may still affect your body?

Informed Consent & Acknowledgment

I voluntarily consent to assessment and manual therapy care as part of the Rapid Release program. I understand this work is not a substitute for medical diagnosis or treatment, that I will communicate openly about my comfort and any changes, that I may discontinue at any time, and that results vary and are not guaranteed. I have read the "What to Expect" section above.

Physician consultation: I understand I should consult a physician or a healthcare provider I trust before beginning this or any new movement program — especially if I have a pre-existing condition, injury, or medical concern. I confirm I have done so, or I knowingly choose to proceed.

I have read and agree to the above. *

Client Printed Name Signature

Parent / Guardian Name (if minor) Relationship to Minor

✓

Thank you

Your intake has been received. I'll review it before your session. If anything changes before we meet, just let me know.