Virtual Sessions (Phone or Zoom)

As effective as in person sessions, with the added comforts of your chosen space.

Learn to effectively use

Stress Management tools, Hypnotherapy &

Guided Self-Massage Therapy

to accomplish your personal, spiritual & professional goals.

Rn Within

R

CSMC., Certified Stress Management

Consultant

CHt.,Certified Hypnotherapist

International Association of

Counselors & Therapists

(IACT) registration #

010418-8974

Stephanie Carper-Smith

626-244-1818

About Stephanie: Experience & Training

Home

Body Wisdom

Location

Hypnotherapy Approaches

Q & A

Poetry & Mindfulness Exercises

Medical Questionnaire

CMT.,

California Certified

Massage Therapist

California Massage Therapy

Council (CAMTC )

Certificate #9656

Please complete the medical questionnaire 24 hours prior to your first in person session. In person sessions are now available on a limited basis.

Medical Questionnaire

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.

First Name

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 sitiation & any helpful information regarding the location of the session. (stairs/no stairs, indoors or outdoors, home or office, etc.)

For Massage Therapy, only oils are used, instead of lotion, due to therapists skin sensativity. Gloves might be worn. Please choose an oil preference.

CBD Oil may be added for an additional $5/session/person. Essential Oils may be added for an additional $5/session/person. Do you want any add ons?

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? Are there areas needing focused attention? Do you prefer light or deep pressure? Please share anything else you feel might be important.

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

Have you had a fever in the last 24 hours of 100°F or above?

Yes

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

Yes

Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?

Yes

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

Are you able to take your temperature before my arrival? (if no, I may take your temperature upon arrival)

Yes

Masks must be worn by Client & Therapist for in person sessions. Do you have a mask to wear during your session? If no, a mask may be provided for you.

Yes

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

To proceed with receiving care, I confirm and understand the following (check the box on the side). 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 extremely 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, my CHt., CMT 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 care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult. 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 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 with COVID-19 through this treatment and give my express permission to proceed with the scheduled care. I may request a copy of this consent form. I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. 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 TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT THIS CONTENT. I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FORWHICH I SEEK CARE from Stephanie Carper-Smith.

I voluntarily agree and sign this waiver and assumption of risk with full understanding that (Stephanie Carper-Smith, RnR Within) hereafter referred to as Certified Hypnotherapist (CHt) and Certified Massage Therapist (CMT), 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 the CHt., CMT., or any of it’s associates 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 Hypnotherapy and Massage Therapy are not intended to replace my traditional medical care and are complimentary to it. The CHt., CMT., may make suggestions about my health and encourage me to make positive changes but it is my responsibility and the suggestion of the CHt, CMT that I seek guidance from a Qualified Medical Professional. I further agree that the CHt., CMT., and any and all of it’s associates and locations where sessions are held, assume no responsibility for the outcome of the process or for guaranteeing its efficiency. I certify that I am competent to assume any risks and I take full responsibility for the results. I understand my CHt., CMT., is authorized and trained to help me achieve my personal, professional and self-improvement goals. I understand that some issues that may be addressed require a Medical and/or Psychological referral inorder to proceed. If anything changes with my health I agree to inform my CMT., CHt before my scheduled session. Sessions may be cancelled & rescheduled without penalty due to health and pandemic reasons. Last minute cancellations due to non emergency or non health reasons may be assessed a cancellation fee of up to the full appointment cost.

Your Signature

Today's Date

Sucessfully Submitted, Thanks!

Virtual Sessions (Phone or Zoom)

As effective as in person sessions, with the added comforts of your chosen space.

Learn to effectively use

Stress Management tools, Hypnotherapy &

Guided Self-Massage Therapy

to accomplish your personal, spiritual & professional goals.

Rn Within

R

Stephanie Carper-Smith

626-244-1818

CMT.,

California Certified

Massage Therapist

California Massage Therapy

Council (CAMTC )

Certificate #9656

Please complete the medical questionnaire 24 hours prior to your first in person session. In person sessions are now available on a limited basis.

Medical Questionnaire

For private sessions & customized group sessions Zoom or Phone

626-244-1818

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