Spinal Flow Client Form | Lead By Light, LLC

Spinal Flow Technique Client Intake Form

Please fill out the following form in order to participate in Spinal Flow Session(s).

First name

Last name

Phone Number

Date of Birth

About Your Health:

The human body is designed to be healthy. Throughout life, events occur which damage your health expression. This case history will uncover the layers of damage, especially to your nerve system, which have resulted in poor health. On this weekend we will begin to correct these layers of damage and recover your innate health potential.

Loss of Wellness (Birth - Age 5):

Let’s begin at birth when you may have first damaged your nerve system, lost your wellness and began your journey to ill health.

Was your mother's delivery with you long and/or difficult?

Yes

Were Forceps or suction used?

Yes

Was the birth Cesarean? (C-Section).

Yes

Breech / Cephalic?

Yes

Do you know of any stressful situation that may have been present for your mother or father or both?

Growth and Development Through Childhood

Answer the following questions through the lens of your younger self please.

Did you have colic, reflux or difficulty feeding?

Yes

Did you experience any childhood traumas, if so please explain

Did you roll out of bed or have any falls as a child?

Yes

Did you have any childhood illnesses? If so, please explain

Where there any other stressful events that occurred at this time? (0-5years)

Loss of Whole Body Health (Age 5 - Present)

As you increase the layer of damage you probably begin to experience symptoms and random bouts of sickness.

Did you/ Do you smoke?

Never

Weekly

Daily

Did Previously

Did you/ Do you drink alcohol?

Never

Weekly

Daily

Did Previously

Did you/ Do you take recreational drugs?

Never

Weekly

Daily

Did Previously

Please list below the recreational drugs you take along with the days/weeks since taking. (Type "N/A" if non-applicable) Please feel free to add any additional information about drinking/smoking as well.

Do you take over the counter drugs? (Prescriptive or Non-Prescriptive

Never

Have Recently

Currently Taking

Please list any prescriptive/non-prescriptive drugs you have recently taken below, along with what they are for & the frequency you take them.

Do you eat an healthy diet?

Yes, Always

I eat healthy for the most part but struggle with consistency

No, I need to work on finding a healthier diet that works for me and my body.

Have you had any surgeries or organs removed or replaced? If so, please specifiy.

Have you had any accidents/sports injuries of any sort? (ie: car accidents, bad falls, broken bones, concussions, etc.)

What position do you sleep in?

Side

Stomach

Back

What are your sleeping habits like? Required

Trouble Sleeping

Sleep Debt

Wake Up Tired

Oversleep

Do you have occupational stress? (Please Explain)

Do you have Mental, Emotional, Or Physical Stress? If so, please explain.

What stressful or traumatic events do you believe caused or had an impact on your health & well being? Please provided age timeframe that these events occured.

What are the above impacts stopping you from doing?

Present State Of Health

Connect with your body, mind & emotions in this moment & answer the questions below.

What is your body telling you right now? What symptoms are you experiencing? Please explain & describe what is happening in your body mentally, emotionally & physically.

When did these symptoms listen above start? (ie- Age, Year, or 'X' Amount o f years ago, etc.)

What do you think caused this current state of health?

What activities/environments aggravate or worsen your condition?

What lessens or improves your condition?

Have you had any trauma or abuse in your life? (If so, please explain).

If all of this were to go away tomorrow, what would be different about your life?

Are you living the life you want to be living?

On a scale of 0-10, how happy are you? (10 being the MOST Happy)

On a scale of 0-10, how stressed are you? (10 being the MOST stressed)

Are you ready to make changes to your life in order to heal, even if these changes are inconvenient to your current lifestyle? Required

Yes!

No.

What are you hoping to get out of your Spinal Flow Sessions?

Please let me know in a few sentences how I best support you/assist you? (ie: Hold Space Silently, Verbally encourage me to surrender to the experience, remind me of how powerful my body is)

By signing this form, I agree and consent to participate in and have Spinal Flow work done on me from Lead By Light, LLC. I understand that Jordyn Kurtz of Lead By Light , LLC is not a licensed health professional. Any & All current spinal flow clients agree to participate in these sessions at their own free will & agree and understand that sessions may be recorded and submitted for certification purposes. I understand that with any healing process and work on my body, my symptoms may worsen before they get better. I understand this care is designed to assist the body with healing by helping to remove stressors from the body. I understand that healing takes time and there is no quick immediate fix to my problem, and health is a process. I understand that my body may feel sore and or worse, my digestion may change & I may be emotional the days following spinal flow sessions. I understand that staying hydrated and caring for my body outside of sessions is my responsibility and by taking care of my body and staying hydrated I will lessen the potential side effects I may experience after my spinal flow sessions.

Potential side effects of Spinal Flow Technique include but are not limited to the following:

Dizziness , Headaches, Vertigo, Nausea, Fatigue, Heightened Emotionality, Cold/Flu Like Symptoms, Tingling Body Sensations & Changes in Digestion.

The body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.
Any suggestion made by the practitioner, Jordyn, Lead By Light, LLC, will be to assist my body's natural healing ability to achieve a balanced energetic state, to the extent that my body & or my highest knowing will allow.
No guarantees as to the results of treatment are expressed or implied by the practitioner.

Jordyn Kurtz is not a licensed physician and will neither diagnose nor prescribe any condition that I might have nor does she make any specific claims regarding results from the Spinal Flow sessions that I receive.

I agree to:

Raise any questions or concerns about anything I do not understand prior to our session(s).
Pay all session fees in full prior to session(s).
Increase my water intake prior to & after my session(s)
Consider any suggestions that the practitioner may raise concerning referrals to other health care practitioners, homework, or my desired focus/introspection.
Take full responsibility for my own health care.
Give consent to Jordyn Kurtz & Lead By Light, LLC to conduct a Spinal Flow Technique Session. I acknowledge that this includes physical touch & I am fully aware of the risks and provide consent to Lead By Light, Jordyn, to conduct a Spinal Flow Technique session(s).

Release of Liability Clause:

I, or my representative(s) agree to fully release and hold harmless, Jordyn Kurtz of Lead By Light, LLC from and against any and all claims or liability of any nature arising out of or in connection with my session(s). My questions have been answered to my satisfaction regarding my Spinal Flow Technique Practitioner's background & credentials and what I might expect from this session and potential side effects. I understand that all issues related to my sessions will be kept in confidence unless specified in writing, or governed by law.

I have read this document completely & agree, consent to & understand all of the above. I also understand that by signing this form I release & voluntarily surrender certain legal rights.

I am the parent or legal guardian of the minor who will participate in this session & the minor is choosing to participate at their own free will with my consent.

I accept terms & conditions.

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Today's Date:

Your Signature

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