I understand that the craniosacral and fascial bodywork my child receives at Innate Wisdom Therapy is gentle work intended for relaxation, the relief of tension, and general well-being. I understand it is not a substitute for medical diagnosis or treatment, and that I am encouraged to keep my child's pediatrician informed of any health concerns. I have shared accurate health information to the best of my knowledge.
I certify that the above medical information is correct to my knowledge.
I authorize Innate Wisdom Therapy, LLC to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor, referring doctor, or professional on my team as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapists' day that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation fee to the card on file.
I give permission for Innate Wisdom Therapy to capture photos and/or videos of me and/or my child during care. I authorize the use of approved images for educational, social media, website, and marketing purposes. I understand identifying information will not be shared without additional permission, and I may decline without affecting my care.
All information shared during this session and recorded in this intake form is confidential and will be maintained in compliance with HIPAA regulations.