New Client Intake Form

This form takes about 2 minutes and your information stays private.

The intake helps me understand your body, your current state, and what you want from our time together — so your session is grounded, effective, and tailored to you. Take your time.

First Name

Last Name

Phone no.

Date of Birth

Occupation

How did you hear about me?

What is the main reason you booked a session today?

Where do you feel it most in your body?

Head / Jaw

Neck / Shoulders

Upper Back

Lower Back

Hips

Arms / Hands

Legs / Feet

Full Body

Stressed / Burnt Out

Emotional Overwhelm

Other

How long has this been affecting you?

A Few Days

A Few Weeks

A Few Months

Over a Year

On and Off for a Long Time

What's the ideal outcome you would like to feel after the session?

How would you describe your current stress levels?

Extremely High

High

Moderate

Low

How would you describe your energy levels lately?

Solid

Up and Down

Fatigued

Running on Empty

How is your sleep currently?

Good

Light / Fragmented

Poor

Insomnia

Do you do any regular practice or sport? If yes, what type?

Do you have any of the following conditions?

Recent Surgeries

Heart Conditions

Pregnancy

Nerve Issues / Numbness

Chronic Pain Diagnosis

Do you have any injury, or physical limitation? Please, share anything else that you would like me to know or that I should be aware of before our session.

How would you prefer the session to feel?

Pressure Preference

I understand that Zenthai Shiatsu is a non-medical, holistic therapy. I take responsibility for communicating any discomfort or concerns at any time during the session.

I consent to have this website store my submitted information so they can respond to my inquiry.

Thank you, I look forward to meeting you and working with you soon.