Rn Within

R

Stephanie Carper-Smith 626-244-1818

Certified Stress

Management Consultant

Certified Professional Hypnotist

International Association of

Counselors & Therapists

(IACT) registration #

010418-8974

Home

Location

Client Health Form

IMG_8156_edited_edited_edited_edited_edi

Certified
Massage Therapist

California Massage Therapy
Council (CAMTC )
Certificate #9656

Please complete the health intake form prior to your first in person session.

Client Health Intake

Please share the following information about you & your health. Your information is confidential. Please Inform Stephanie of any changes in your health between now and your scheduled sessions.

Legal First Name, Preferred Name & Preferred Pronouns

Last Name

Email Address

Address

Occupation

Phone

Date of Birth

How did you hear about Stephanie Carper-Smith?

Emergency Contact (relationship, name & phone#)

Sessions are provided at your location so please describe the parking situation & any helpful information regarding the location of the session. (stairs/no stairs, indoors or outdoors, home or office, etc.)

For Massage Therapy due to providers skin sensativity, oils are usually used instead of lotion. Please choose an oil preference. If providing your own sheets for massage, be aware that oils can stain sheets & provide an appropriate set or a set can be provided upon request.

Are you currently suffering from a medical condition, communicable disease, illness, or injury? Have you been hospitalized in the last 12 months?

Yes

If you answered yes, please elaborate

What do you hope to accomplish with your sessions? What areas need focused attention? For massage, do you prefer light, medium or deep pressure? Please share anything else you feel might be important.

Have you had any past diagnosis of Covid?

Yes

If you answered yes, when? Please describe your current state of recovery.

Have you had the complete COVID 19 Vaccine? If not, do you plan to get the vaccine?

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? Have you had any Covid Symptoms recently?

Yes

If you answered yes, please elaborate

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Yes

Do you have any questions or have anything important to add?

To proceed with receiving sessions, I confirm and understand the following. I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that I am the decision maker for my health care. To the best of their ability, Stephanie will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended techniques, and the benefits and risks associated with the provision of in-person sessions during a pandemic. I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time sometimes in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected and give my express permission to proceed with any scheduled sessions. I may request a copy of this consent form. I KNOWINGLY AND WILLINGLY CONSENT TO THE in-person session WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING in-person sessions. I CONSENT TO PROVIDE A CLEAN SANITIZED SPACE FOR MY SCHEDULED SESSIONS, WHICH INCLIDES A BATHROOM SPACE FOR THE SESSION PROVIDER TO USE. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION. I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO PROCEED WITH ALL SESSIONS. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT THIS CONTENT.

I voluntarily agree and sign this waiver and assumption of risk with full understanding that Stephanie Carper-Smith, RnR Within, referred to throughout as Stephanie, is not a Psychotherapist, Psychologist, or a Medical Doctor and does not diagnose or treat any physical or mental disorders. I further agree not to hold liable Stephanie, or any associates, third party booking apps and locations where sessions are held, for any problem or claim of personal injury, if any arise from any session or my involvement in the activities. I certify that I am competent and am stable enough mentally, emotionally, spiritually, and physically, to participate in the activities I have signed up for. I understand that techniques practiced and offered by Stephanie are not intended to replace my traditional medical care and are intended as complimentary to it. I understand it is my responsibility to seek guidance from a Qualified Medical Professional. I understand Stephanie, is certified and trained to help me achieve my personal, professional and self-improvement goals. I understand that some issues may require a Medical and/or Psychological referral in-order to proceed. If anything changes with my health I agree to inform Stephanie before my next scheduled session. Sessions may be cancelled & rescheduled without penalty due to health and pandemic reasons unless otherwise specified by third-party scheduling app agreement. Last minute cancellations due to non-emergency or non-health reasons may be assessed a cancellation fee up to the full appointment cost. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE PAST, PRESENT AND FOR ANY FUTURE SCHEDULED SESSIONS I SEEK from Stephanie Carper-Smith both directly and scheduled thru any third-party app.

If under 18 years of age, signature of parent or legal guardian is required. I, (enter legal name of guardian below) parent/legal guardian of (enter legal name of minor below) hereby give my permission for the minor listed below to receive any scheduled sessions with Stephanie Carper-Smith. I understand and agree to all included disclosures on the minors behalf.

Your Signature or if under 18, Signature of Parent or Legal Guardian:

Today's Date

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