Name
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First Name
Last Name
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
What brings you to HAVEN at this time? (You can share as much or as little as you like)
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How would you describe your current stress levels?
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How does stress usually show up for you? (tick all that apply)
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What would you most like to feel after your session? (e.g. calm, clarity, lightness, groundedness)
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Is there anything we should know to help you feel safe, comfortable, or supported during your session? (e.g. past trauma, sensory sensitivities, touch preferences, nervousness about NSDR, etc)
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Are there any areas of the body you’d like to avoid during massage?
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Do you have any medical/health conditions, allergies, injuries, recent surgeries, accidents, or are you pregnant? Are you currently taking any medications, being treated for any conditions, or in therapy? Please list all that apply and give us much detail as possible (This helps us ensure your session is safe and appropriate)
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Do you have a history of seizures, epilepsy, or psychosis?
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Would you like to receive a post-session grounding audio by email or WhatsApp? that apply)
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How did you hear about HAVEN?
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Do you consent to receiving this session as a complementary wellness treatment, and understand it does not replace medical or psychological care?
*
You’re all set.
Thank you, we’ve received your details and will hold them in confidence.
You’re warmly invited to arrive a few minutes early on the day of your appointment to relax at the on-site café. We will collect you from there at your appointment time.
