CranioSacral Sign Up

Sign up for 3 FREE Sessions of CranioSacral Therapy

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Name *

First

Last

Phone Number *

Email *

Date of Birth *

Have you had CranioSacral Therapy or Reiki done in the past? *

CranioSacral Reiki Both Niether

Main problem for which you are seeking help? *

Other current problems do you hope it might help? *

How long have you had the main problem? *

How is the main problem impacting your life? *

Minimal Moderate Major

Have you seen a doctor for the condition? *

Yes No

What medication, if any do you take for it? *

Have you been treated with any alternative therapies? If yes please describe *

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Disclaimer: Massage therapy Services are for the primary purpose of Short-Term relaxation and the relief of muscular tension. Massage therapy services are in no way a substitute for examination, diagnosis or treatment by a physician. The individual providing massage therapy services are not qualified to diagnose, prescribe or treat any physical or mental illness and are not qualified to perform spinal or skeletal adjustments. All information we provide is educational in nature and is to be used at your own risk.