Tell us a little about yourself

mind/body exploration intake form

 We take privacy very seriously. Your personal information will never be shared with any outside party.

Your Contact Information
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Your Emergency Contact
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General Information
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Health Questionairre
The following questions help us to address concerns and assess if you have any conditions that might be contraindicative to your Mind/Body Exploration experience. Please check all that apply and explain if necessary.

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* If so, please refer to our Contraindications page.
   
   
   
   

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Your Mind/Body Experience

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Release of Liability

I agree to check myself, care for myself and be fully responsible for myself as I use the floatation chamber, shower and room and as I travel in and move upon the surfaces of both my mind, my physical, and my emotional environments. I have made no misrepresentations to Still Point Wellness, any of its agents or employees regarding my physical or mental conditions. I accept and expressly assume for my use the isolation tank, shower and room facilities and accept full responsibility for the use, and while I am in possession, the control of all of this equiptment. I hereby agree and accept the terms and conditions for this contract and acknowledge that Still Point Wellness has provided no warranties, expressed, oral,or implied, about my expectations being met or anticipated, or unforeseeable experiences. I understand that I will be shown how the floatation tank, shower, and all the room systems work and that I will be instructed in the proper use. I understand that floating, showering, being in control and care of myself, my room and its environment is my own controlled activity and that the floatation, showering, movements and isolation experiences involve a risk of possible injury to me and I hereby agree to freely and expressly assume and accept any and all risks of injury and release Still Point Wellness from liability should injury occur.

Still Point Wellness does not condone the use of drugs and/or alcohol while using the salt water floatation chamber. I agree to abstain from using drugs and/or alcohol while I am in the floatation chamber.

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, 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. Because massage 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so.

If I make any sexual advancements or innuendos the session will be terminated immediately without a refund.

I agree to give 48-Hour notice if I choose to reschedule or cancel an appointment for any reason other than a family emergency or sudden illness. If I cancel without 48-hour notice or do not show up to my appointment I agree to pay the full cost of the mind/body exploration session.

By submitting this form I affirm the accuracy of the information I have provided and understand and agree to the policies above.

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