This intake and consent form collects contact, medical history, and payment information from clients of Adrienne Provent, a certified crystal healer, licensed massage therapist, and licensed practical nurse. Clients must provide contact details and sign the form to receive services. All client information will be kept confidential per HIPAA regulations. The form requests medical conditions, medications, past injuries, massage experience, and pressure preferences to safely provide therapeutic bodywork. By signing, clients consent to treatment terms and payment methods.
This intake and consent form collects contact, medical history, and payment information from clients of Adrienne Provent, a certified crystal healer, licensed massage therapist, and licensed practical nurse. Clients must provide contact details and sign the form to receive services. All client information will be kept confidential per HIPAA regulations. The form requests medical conditions, medications, past injuries, massage experience, and pressure preferences to safely provide therapeutic bodywork. By signing, clients consent to treatment terms and payment methods.
This intake and consent form collects contact, medical history, and payment information from clients of Adrienne Provent, a certified crystal healer, licensed massage therapist, and licensed practical nurse. Clients must provide contact details and sign the form to receive services. All client information will be kept confidential per HIPAA regulations. The form requests medical conditions, medications, past injuries, massage experience, and pressure preferences to safely provide therapeutic bodywork. By signing, clients consent to treatment terms and payment methods.
This intake and consent form collects contact, medical history, and payment information from clients of Adrienne Provent, a certified crystal healer, licensed massage therapist, and licensed practical nurse. Clients must provide contact details and sign the form to receive services. All client information will be kept confidential per HIPAA regulations. The form requests medical conditions, medications, past injuries, massage experience, and pressure preferences to safely provide therapeutic bodywork. By signing, clients consent to treatment terms and payment methods.
Sushena Gypsy Intake and Consent Form This Intake and Consent Form has been given to you to provide valuable information in your healing. While sharing most information in this form is voluntary, you must fill out the contact information below, as well as sign and initial the consent and release at the end of this form, for me to work with you. In addition to personal information, you are asked to disclose current and past medical history protected by the Health Insurance Portability and Accountability Act. As such, you have certain privacy rights in this information and in compliance with the law, our HIPPA policy is attached to this form. All information we obtain about you, whether written or shared verbally during our sessions, and whether from you or directly or another source, will be held in the utmost confidentiality. I will never share your information, medical or otherwise, without your express written consent and direction, unless otherwise required by law. While providing personal and medical information about you is entirely voluntary, without this information, you may impair the progress of your sessions and potentially create risks to your health. This is especially true in regard to massage, and it is very important for me to be aware and know your current medications, medical diagnoses, and current and past injuries and surgeries. If you have any questions about how to complete this form, how I use your information, or what your rights are regarding your information, please ask before signing below. For my metaphysical oriented clients interested in astrology and crystal healing, please fill out time and place of birth. Today’s Date: ______________ Name: _________________________________ Email: ________________________ Phone: ___________________________ Is it okay to text: ○Yes ○ No Address: _________________________________________ Apt #: ________________ City: ____________________________ State: _________ Zip Code: _____________ Emergency Contact Person (Name, Relationship, and Phone Number): ______________________________________________________________________ Occupation: __________________________________ DOB: ____________ Time: __________ Place of Birth: _________________________ Adrienne Provent, CCH, LMT, LPN, Sushena Gypsy AZ, CT #07890, FL MA #73273, ME MT#6358, OK #194932 How did you hear about my services? ______________________________________________
Essential Questions
Please list any medications and/or supplements that you are currently taking. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
Medical History: Please check any medical conditions that apply:
Autoimmune (Rheumatoid Arthritis, Eczema Lupus, Psoriasis, Sjogren’s) Bone (Arthritis, Osteoporosis) Cancer Cardiac (Atrial Fibrillation, High Blood Pressure, High Cholesterol) Endocrine (Adrenal Fatigue, Addison’s, Cushing’s, Diabetes) Hematological (Anemia, Polycythemia, Thrombocytopenia) Muscular (Muscle pain and stiffness, recently injured muscle) Neurological (Bell’s Palsy, Epilepsy, Guillain-Barre, Headaches, Head Injuries, Herniated Disks, Migraines, Neuropathy, Parkinson’s, Spinal Cord Injury) Pulmonary (Asthma, COPD, Emphysema, Psychological (Anxiety and/or panic attacks, Eating Disorders, Mood Disorders, Phases of life, PTSD, Transition) Reproductive (Dysmenorrhea, Endometriosis, Fibroids, Menorrhagia, PCOS) Elaboration or anything you would like to add: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
Adrienne Provent, CCH, LMT, LPN, Sushena Gypsy
AZ, CT #07890, FL MA #73273, ME MT#6358, OK #194932 Past Accidents, Injuries, or Surgeries: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ________________________________________________________________
What is your experience with bodywork and/or massage and what are you seeking through this experience? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
How do you prefer your pressure and are there any areas you are uncomfortable having massaged? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
Adrienne Provent, CCH, LMT, LPN, Sushena Gypsy
AZ, CT #07890, FL MA #73273, ME MT#6358, OK #194932 Consent and Release Liability:
I am requesting the services of Adrienne Provent, certified crystal healer,
licensed massage therapist, and licensed practical nurse to perform within her scope of practice and bring her intuition and knowledge to the forefront. All information I have provided in this Intake and Consent Form is accurate to the best of my knowledge. I agree to have sufficient space and a comfortable temperature for my therapist to perform bodywork, as well as the least number of distractions in the household. Table work should be performed on the first floor. I understand that massage is therapeutic, and draping is mandatory during session. I also understand that it is my responsibility to ask for the appropriate amount of pressure if I am uncomfortable at any time. I have been explained to and understand the associated risks with massage, crystal healing, and Reiki, and agree that it is my responsibility to seek further information if I feel the need. I understand I will not be under the influence of any recreational drugs nor under the influence of alcohol. If I am taking medication for pain, I have and will continue to communicate this. I understand that, while certain medical options may be explained to me during my journey of healing, these explanations are in no way any sort of prescription or medical directive. I have been given the opportunity to read Adrienne Provent’s HIPPA privacy policy and read (or waived the right to read) and understand its contents. All sessions are confidential. My therapist has provided a Client Disclosure Form by email and it can be found online at www.adrienneproventlmt.com/downloadableforms and I understand its contents and I accept its terms, without conditions. I agree to my therapist at the time of service. Cash, Cash App- $AdrienneProventLMT, Pay Pal-PayPal.me/AdrienneProventLMT or Venmo-@AdrienneProventLMT, and Square, are acceptable forms of payment. In home therapeutic bodywork rates are $110 for one hour, $145 for a 90-minute, $185 for a two-hour session. Other fees included may be different sessions and upgrades. Driving time may affect the cost of sessions. This applies to Arizona, Florida, Connecticut, Oklahoma, and Maine residents at the time. If there is a different rate, the contracted rate is: ________________
Adrienne Provent, CCH, LMT, LPN, Sushena Gypsy
AZ, CT #07890, FL MA #73273, ME MT#6358, OK #194932 No Show Appointment: Price of session and credit card hold if another appointment would like to be scheduled. Consistent cancellations equals termination of our relationship. By signing here, I agree to all these terms.
X Client's signature
Adrienne Provent, CCH, LMT, LPN, Sushena Gypsy
AZ, CT #07890, FL MA #73273, ME MT#6358, OK #194932
