Intake New Baby or Growing Child

Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please choose all that apply to your baby's birth process:
- Vaginal delivery
- C-section
- Epidural
- Induced labor with Pitosin
- Home delivery
- Hospital delivery
- Midwife supported
- Doula supported
Please share any details about the delivery process that seems important to share

Please list any surgical procedures your baby has received and approximate dates:
Please list any accidents/injuries he/she has experienced and approximate dates:
Are there any known allergies?*

Consent*
I have read and agree to the Soaring Spirits LLC Terms and Conditions
I understand that the craniosacral therapy received here is for the purpose of stress reduction,
emotional and physical release, re-balancing and increasing energy flow in the body. I understand
that Joyce Harader is not a licensed physician and does not practice allopathic medicine in any form.
I understand that Joyce does not diagnose illness, disease, or any other physical or mental disorder.
I have made her aware of existing conditions and will report any changes as they occur.

I understand that it may take more than one session to affect change. I also understand that I
may temporarily experience an energy release that may be uncomfortable. I will not hold Joyce
responsible. I understand that Joyce is available to me if questions or further discussion of the
session is wanted.

I understand that if I need to cancel an appointment, I need to do so with a minimum of 48 hrs.
notice. A cancellation with less than 24 hrs. notice will be charged a full appointment fee.
Your typed name indicates your electronic signature.*
Please type your full name.
Date*
MM slash DD slash YYYY
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

New Baby/Growing Child Intake Form