Patient Intake Form

DEAR CLIENT,

Thank you for your interest in working with me! I’m looking forward to the opportunity to assist you in any part of your healing process. Our treatment will be designed according to your specific needs and each session can vary accordingly. If you are receiving any type of medical care, I do not advise you to discontinue any medical treatment you may be receiving. We will discuss it further when you come to see me in person. I will be another important component of your current care. Please fill out this questionnaire and bring it with you for our first therapy session.

Self-care is an extremely important part of this work and is your responsibility during our work together. If at any time during the session you are uncomfortable, please inform me immediately. I also recommend that you refrain from consuming alcoholic beverages for 24 hours following your treatment and allow yourself to integrate the session, as needed, with rest, water and listening to what your body needs.

Any information you share with me during our session is always kept confidential. I may, however, discuss any particular issue or concern with your doctor or therapist if you need me to do so, always with your permission first.

In signing this form, you acknowledge I may work with you in the above described manner. I look forward to our connection. Please let me know if you have any questions about this form, the session, Physical Therapy or Brennan Healing Science. I’m happy to answer them!

Warmly,

Minsu Blanca DPT, MSPT, PT, CPT, MBA, Certified Hypnotherapist & Energy Medicine Practitioner