• Windows of Wellness Intake Form

  • Personal Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Financial Information

  • How I plan to pay for therapy:*

  • Cancellation Policy

    Amid the ongoing uncertainty of COVID-19, we have modified our cancellation policy to offer greater flexibility to all our clients.  We hope this will alleviate any stress and hesitation you have about an upcoming appointment.  If you need to reschedule for whatever reason, and especially if you are not feeling well, we understand and request for you to please contact us as soon as possible to reschedule.  To further support you, there will be no penalties for cancellations at this time.  

    However, if you do not show up for your appointment and do not notify us in advance that you need to cancel or reschedule, no shows will still be charged a $25 fee.  If you are on a package or annual membership, you will forfeit that session of your package or membership.

  • Credit Card to Hold/Secure an Appointment

    As a new client, we require a credit card to be held on file to secure your appointment.  If you do not show up for your appointment, or do not provide at least 24 hours notice should you need to cancel or reschedule, you will be charged a $25 fee.  That fee will automatically be charged to the credit card number you provide below.

    The credit card number provided below will only be charged if you do not show up or provide adequate notice of a cancellation - no payment is being made upon completion of this Intake Form.  When you arrive for your appointment, you will be able to use your preferred payment method (cash, check, credit card, gift card, etc.) to pay for your session.

  • prevnext( X )
      No Show
      $1.00$1.00
        
      Debit or Credit Card

    • Personal History

    • Do you have any difficulty laying on your front, back or side? (check all that apply)*
    • Are you wearing: (check all that apply)*
    • Are you experiencing any of the following? (Please check all that apply)*
    • Have you been treated for any health conditions in the last year?*

    • History of the Present Problem

    • Have you ever had the same or a similar problem?

    • Please refer to the image below for the next question.

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    • The Sections I have pain (Check All That Apply)

    • Social History

    • Do you do any of the following? (Please check all that apply)*

    • COVID-19 Health Information & Informed Consent

      This section contains important information about your decision to receive services in light of the COVID-19 public health crisis. Please read and fill out this form carefully and let us know if you have any questions.
    • Have you had a fever in the last 24 hours of 100˚F or above?*
    • Do you now, or have you recently had, any respiratory or flu symptoms (including fever, chills, sore throat, cough, muscle aches, or shortness of breath)?*
    • Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?*
    • Have you traveled anywhere outside of the state in the last two weeks?*
    • Have you had a new loss of sense of taste or smell? *

    • The following questions are specific to a new aspect of COVID-19 involving blood coagulation.

    • Can you exercise to get your heart rate and respiratory rate up without any problem?*
    • Have you had a new onset of muscle aches and pain since the emergence of the virus?*
    • Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?*

    • The following questions are related to the available COVID-19 vaccines.

    • Have you been vaccinated?
    • If so, which vaccine did you receive?
    • How many doses have you received?
    • What was the date of your last shot?
       - -
      2 digit month, 2 digit day, 4 digit year

    • Consent for Treatment

      To proceed with receiving care, I confirm and understand the following:

      I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

      I understand that I am the decision maker for my health care. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

      I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care.

      I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION.

      I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT.

      I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.

    • Signature and Submission

    • Please sign your name below to indicate consent to treatment.

    • Date
       - -

    • If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.

    • Date
       - -
    • Reload
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