Client Registration and Goals Form

Rebecca Cook LLC

rcookotr@gmail.com 

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Client Name

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Date of Birth

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Client's Address:

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Name of Emergency Contact

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Emergency Contact email and phone number:

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Reason for purchasing these sessions:

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Have you received these type of sessions/services before? If yes, please indicate your experience/results.

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Please list 3 main goals you hope to achieve from your sessions.

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List current problems you are experiencing and rate these on a scale of 1 to 10 (1 is mild and 10 is horrible):

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How long have each of those problems been going on for?

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How often in a day (or week or month) do you experience each of those as problematic?

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How do these problems impact your daily life (sleep, relaxation, eating, bowel movements, work, quality family time, exercising, having fun, doing things you like, etc.)

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Please list current medications and supplements you are taking and the reason you are taking them (if you do not take any prescription medications, over the counter medications, or supplements write in NONE):

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Have you recently used alcohol or drugs to help cope with the problems listed above? (If yes, please explain in as much detail as you choose.)

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Have you had any surgeries or hospitalizations? (If yes, please share the date and circumstances.)

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Have you had any recent injuries or accidents? (If yes, please share details and how they are affecting you now.)

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Have you ever been diagnosed with a brain injury, concussion, closed head injury, or memory problems? (If yes, please give details. If no, write NONE.)

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Have you had or do you have any medical diagnosis? (i.e. high blood pressure, heart disease, MS, Parkinson's, seizures, chronic pain, fibromyalgia, allergies, IBS, Crohn's, arthritis, spine/disk problems, broken bones, allergies, diabetes, thyroid or hormone problems, depression, anxiety, scoliosis, kidney disease, dizziness, tinnitus, migraines, asthma, cancer, etc.) If yes, please list date of doctor's diagnosis and diagnosis. 

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If you have current or regular muscle of joint pain/stiffness/numbness/tingling/swelling please list area(s) involved:

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Are you pregnant?

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Do you wear dentures?

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Do you wear a hair piece or wig?

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Do you have a contagious disease?

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Do you have congestive heart failure?

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Do you have problems with blood clots?

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Do you have a cranial tumor?

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Do you have an aneurysm?

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Do you have any current infections?

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Do you have a shunt?

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Have you had a recent head injury?

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Have you recently thought about suicide or harming yourself?

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Have you recently thought about harming others?

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Are you willing and able to be open and honest with your coach/practitioner in your sessions?

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If I am uncomfortable with anything in my session(s) I will immediately inform my coach/practitioner.

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Because sessions should not be performed under certain medical conditions, I affirm that I have stated all my known conditions and answered all questions honestly. I agree to keep the coach/practitioner updated as to any changes in my medical and personal profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

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I understand that any illicit or sexually suggestive remarks or advances will result in immediate termination of the session, and I agree that I will be liable for payment of the scheduled appointment.

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I further understand that wellness sessions should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware.

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

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I have read this document and been given the opportunity to ask questions regarding this document and any sessions I am choosing.
(Place your initials in the box.)

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I take responsibility to inform my practitioner of any changes in my health status at least 24-hours prior to any session.
(Place your initials in the box.)

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I give permission for hands-on touch in sessions as indicated (i.e. in-person sessions).
(Place your initials in box.)

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Electronic Signature for the Client or Legal Guardian: Please type your name in the box below*

*Typing your name in the box below constitutes your electronic signature acknowledging the information on this form is accurate and correct. Your electronic signature is legally binding and by signing you acknowledge you are legally authorized to do so.

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Are you the client or the client's guardian?

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Date this form was completed.

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