Client In-Take Form

Name

First Name

Last Name

Phone

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Occupation / Industry

Emergency Contact

Please list a name, relation, and a phone number of an emergency contact.

How did you hear about California Cuddle Company?

Who can we thank for referring you to us?

1. Have you ever had a professional cuddle before?

Yes

If yes, how often do you receive therapeutic cuddles?

2. Do you have any difficulty laying on your front, back or side?

Yes

If yes, please explain:

3. Do you have any allergies to oils, lotions or ointments?

Yes

If yes, please explain:

4. Do you have sensitive skin?

Yes

5. Are you wearing:

contact lenses

dentures

hearing aid

6. Are you experiencing stress in your work, family, or other aspects of your life?

Yes

If yes, how do you think it has affected your health?

muscle tension

anxiety

insomnia

irritability

other [describe below]

Other: How do you think it has affected your health?

7. Is there a particular area of the body where you are experiencing pain or sensitivity?

Yes

If yes, please identify:

8. Do you have any particular goals in mind for this cuddle session?

Yes

If yes, please explain:

9. Are you currently under medical supervision?

Yes

If yes, please explain:

10. Are you currently taking any medications?

Yes

If yes, please list:

Please explain any condition that you have marked above:

15. Is there anything else about your health history that you think would be useful for your cuddle practitioner to know to plan a safe and effective cuddle session for you?

Signature

I, ____________________________________________ (sign name) understand that the cuddle I receive is provided for the basic purpose of relaxation and relief of stress and tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the position and/ or pressure may be adjusted to my level of comfort. I further understand that therapeutic touch should not be construed as a substitute for medical/ mental examination, diagnosis, or treatment and that I should see a physician, councilor or other qualified medical specialist for any physical or mental ailment that I am aware of. I understand that the touch therapists are not qualified to perform, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Since cuddle therapy should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so.

California cuddle company

san diego, CA