Contact/Forms | Therapy Roots LLC

Therapy Roots

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Contact/Forms

therapyrootsllc@gmail.com

You can also contact me via phone (call/text): 763-226-5198

Contact us

Name *

Email address *

Message *

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Intake Form:

*To be filled out after scheduling an evaluation. This intake form is for Biodynamic Craniosacral Therapy. A different Intake form will be provided for Myofunctional Therapy. Forms can also be completed at time of initial evaluation/first session.

Name *

Email address *

Today's Date *

Date of Birth *

Phone Number (000-000-0000) *

Address *

City *

Zip/Postal Code *

Occupation *

Have you received Biodynamic Craniosacral therapy or Myofunctional Therapy before? *

Yes
No

If so, what service did you receive and what was your response? *

What are your current health problems you are experiencing and what are your reasons for coming in? *

List any other healthcare providers or modalities you are currently working with or have worked with in the past. *

What are your goals for this treatment? *

Past surgeries or hospitalizations? *

Check any major symptoms you are currently experiencing: *

Chronic Pain
Muscle Tension
Headaches/Migraines
Fatigue
Digestive Issues
Sleep disturbances
Anxiety/Depression
Numbness/Tingling
Swelling
None
Other

Please list current areas of pain on a scale of 0-10 with 10 being the worst ever and 0 being none at all. Please include up to 3 injuries or pain areas. *

What type of birth did you experience? *

Vaginal
Cesarean (C-section)
Forceps
Vacuum
Other:

Marital Status *

Single
Married
Divorced
Separated
Widowed
Partnered
Prefer not to say

Are you currently under any medical restrictions? *

Yes
No

List any medications you are currently taking. *

List any vitamins or supplements you are currently taking. *

Do you have a regular health care provider? *

Yes
No

Please list any major illnesses or diagnoses (past or present): *

What is your current stress level? *

Severe
High
Moderate
Mild
None

What is your primary source of stress? *

How do you cope with stress? *

Are you currently pregnant? *

Yes
No
N/A

Have you given birth before? *

Yes
No
N/A

Are you the parent of any children? If so, please list their names and ages. *

Family History. *

Leave this field empty