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SERVICES
ABOUT
eBOOK
FOR CLIENTS
- ADULT INTAKE FORM
- CHILD INTAKE FORM

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HOME
SERVICES
ABOUT
eBOOK
FOR CLIENTS
- ADULT INTAKE FORM
- CHILD INTAKE FORM

HOME
SERVICES
ABOUT
eBOOK
FOR CLIENTS
- ADULT INTAKE FORM
- CHILD INTAKE FORM

Intake Form for Adult Clients

Anchor 1

Begin your Journey with Holly

If you have not had a session with Holly previously, please complete & submit the Intake Form below

Adult Intake Form

NEW CLIENT INTAKE FORM FOR ADULTS

FOR BODYWORK AND/OR WELLNESS SERVICES WITH HOLLIANNE DELVALLE / HOLLYSTIC ALCHEMY

YOUR INFO

First name*

Last name*

Phone*

Email*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

YOUR EMERGENCY CONTACT

EMERGENCY CONTACT: First & Last Name*

EMERGENCY CONTACT: Phone Number*

A LITTLE BACKGROUND

Have you received CranioSacral Therapy, body work, or massage therapy before?*

Yes

No

If yes, what kinds of bodywork have you had experience with & when?

Have you ever worked with ...*

Therapy

Somatic work

Energy work

Body-based trauma release

None of the above

HEALTH HISTORY

OVERALL WELLBEING

Do you currently experience ...

Headaches or migraines

Neck pain

Back pain

Pelvic pain

Digestive issues

Where does your body hold the most tension?*

Do you currently exercise? And if so, how many times/hours per week per week do you intentionally move your body?*

Do you have any known diagnoses?

MEDICATIONS & HEALTH

Are you on any medication?*

Yes

No

If you answered yes, which medications are your currently taking?

Have you taken long-term medication in the past?

Do you use ... (1)

Hormones

Birth control

Thyroid medication

Anxiety or depression medication

BIRTH & EARLY LIFE HISTORY

Were you born... (1)*

Vaginal

C-Section

Assisted (forceps, vacuum, etc)

Unknown

Were you born ... (2)*

Full term

Premature

Post-term

Unknown

Do you know of any complications during pregnancy or birth? If yes, please describe

Were you separated from your mother at birth (NICU, incubator, medical intervention)?

Were you ... (3)

Breastfed

Bottle fed

Both

Unknown

CHILDHOOD MEDICAL HISTORY

Do you recall frequent illnesses as a child (ear infections, strep, bronchitis, asthma, allergies, etc)

Any chronic conditions during childhood?

Did you receive routine childhood vaccinations?*

Yes

No

Partial

Unknown

DENTAL & ORAL HISTORY

Did you ever have ... (4)

Teeth pulled (including wisdom teeth)

Root canal(s)

Dental surgery

Jaw surgery

Select any/all that apply

Did you ever have ... (5)

Braces

Retainers

Palette expanders

Headgear

Select any/all that apply

Do you currently experience ...

Jaw tension

Clicking or popping

Clenching or grinding

TMJ pain

Select any/all that apply

Do you breathe mostly through your ...

Nose

Mouth

Both

Unknown

ACCIDENTS, INJURIES & TRAUMA

Have you experienced ... (7)

Concussion

Whiplash

Fall(s)

Sports injury

Head injury

Car accident(s)

If you selected "yes" for any of the above, please list approximate ages & details of the incident(s), if applicable:

Have you had any broken bones, major sprains, or orthopedic surgeries? If so, what and when?

SURGICAL & MEDICAL HISTORY

Have you ever had surgery? (Including tonsils, adenoids, sinus, dental, orthopedic, abdominal)

Do you currently have any implanted devices (IUD, plates, screws, mesh, etc.)?

Have you ever been under anesthesia?

No

Once

Multiple times

NERVOUS SYSTEM & SENSORY EXPERIENCE

Do you experience ...

Anxiety

Depression

Panic

Overwhelm

Chronic stress

Fatigue

Sleep issues

Emotional numbness

Hypervigilance

Are you sensitive to ...

Light

Sound

Touch

Smells

Crowds

Do you ever feel "disconnected" from your body?

EMOTIONAL / PSYCHOLOGICAL HISTORY & LIFE STRESSORS

Optional, but Helpful -- you may skip any question you do not feel comfortable answering

Do you feel safe in your body most of the time?

Yes

Sometimes

Rarely

Have you experienced ... (8)

Loss or grief

Chronic stress

Childhood emotional trauma

Relationship trauma

Medical trauma

Birth trauma

Have you experienced any significant emotional stress or trauma at any point in your life?

Yes

No

Unsure

If yes, and you feel comfortable sharing, you may briefly describe (no details required):

Do you feel that past emotional experiences, or any any major life events, may still affect your body or nervous system today?

YOUR GOALS

What would you most like support with at this time?

What does "feeling better" look like for you?

HOW DO WE KNOW EACH OTHER?

How did you hear about Hollystic Alchemy?*

If you met Holly at an event, or through a friend, or as a referral, let me know who to thank for the introduction!

PLEASE SIGN & DATE

Signature*

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Today's Date*

Month

Day

Year

Note: your personal information will never be shared, and is use to inform your session & for Holly's professional use only

528 48th Street Court East

Bradenton, FL 34208

hollysticalchemy@gmail.com

Holistic healing in SRQ ... and beyond!

Lic #MM46204 | #MA102333

✶ CranioSacral Therapy

✶ Manual Lymphatic Drainage

✶ Medicupping ✶ EFT Tapping

✶ Primitive Reflex Assessments

✶ Bioresonant Feedback Scans

✶ Inner Voice Scans

© HOLLYSTIC ALCHEMY by Holly DelValle 2023 - 2025

DESIGNED BY ANNIE LUCID

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