| If you would like to schedule an appointment at Tera's NYC office, please call 212.371.0700 or 212.249.7711. If you would like to schedule and appointment at Tera's Santa Fe office, please call 917.597.9698. After scheduling your appointment please fill out the intake form below. |
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FINANCIAL POLICY
PAYMENT (CHECK OR CASH) IS REQUESTED AT THE END OF EACH VISIT, UNLESS SPECIFIC ARRANGEMENTS ARE MADE.
CANCELLATION POLICY
THE TIME OF YOUR APPOINTMENT IS RESERVED FOR YOU. APPOINTMENTS CANCELLED WITH LESS THAN 48 HOURS NOTICE WILL BE CHARGED FOR PAYMENT IN FULL. |
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| WHAT ARE YOUR GOALS FOR RECEIVING THIS WORK? |
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| PERSONAL HEALTH HISTORY |
| HEIGHT |
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| WEIGHT |
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| DO YOU HAVE ANY AREA OF YOUR BODY THAT NEEDS SPECIAL CONSIDERATION? |
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| IF YES, PLEASE EXPLAIN |
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| DATE OF LAST MEDICAL EXAM |
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| ARE YOU CURRENTLY UNDER MEDICAL CARE? |
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| IF YES, PLEASE GIVE THE NAME OF PROVIDER AND CONDITION BEING TREATED |
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| ARE YOU PRESENTLY TAKING ANY MEDICATION? |
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| IF YES, PLEASE LIST NAMES OF MEDICATION(S), FOR WHAT CONDITION |
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| ARE YOU PRESENTLY USING ALCOHOL OR NICOTINE? |
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| HAVE YOU EVER WORN BRACES? |
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| HOW WOULD YOU DESCRIBE YOUR DIET? |
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| DO YOU TAKE VITAMINS, HERBS OR OTHER DIETARY SUPPLEMENTS? |
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| IF YES, PLEASE DESCRIBE |
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| HAVE YOU EVER RECEIVED BODYTHERAPY? |
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| IF YES, PLEASE DESCRIBE AND FOR WHAT PERIOD OF TIME |
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| ARE YOU CURRENTLY RECEIVING REGULAR BODYWORK OR OTHER THERAPY? |
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| HEALTH HISTORY |
| HAVE YOU EVER HAD ANY TYPE OF ACCIDENT? |
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| IF YES, PLEASE DESCRIBE AND INCLUDE DATES |
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| HAVE YOU EVER BROKEN ANY BONES OR HAD SEVERE FALLS? |
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| HAVE YOU EVER HAD ANY TYPE OF SURGERY? |
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| IF YES, PLEASE GIVE TYPE(S) AND DATE(S) |
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| DO YOU HAVE ANY LIMITS IN MOBILITY? |
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| IF YES, PLEASE DESCRIBE |
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| DO YOU EXERCISE? |
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| PLEASE DESCRIBE TYPE AND FREQUENCY |
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| DESCRIBE METHODS YOU USE TO MANAGE STRESS IN YOUR LIFE |
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| WHAT DO YOU DO FOR FUN? |
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| ANY ADDITIONAL COMMENTS REGARDING YOUR HEALTH – PLEASE DESCRIBE ANY OTHER CHRONIC OR ACUTE CONDITIONS, I.E. LOW/HIGH BLOOD PRESSURE, DIABETES, ULCER, SLEEP DISORDERS, ETC. |
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| ANYTHING ELSE ABOUT YOUR LIFE HISTORY OR CURRENT SITUATION THAT I SHOULD KNOW AT THIS TIME? |
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| BIRTH INFORMATION/HISTORY |
| AN UNDERSTANDING OF YOUR BIRTH IS A SIGNIFICANT PART OF THIS WORK. TRAUMA MAY HAVE OCCURRED DURING THE BIRTH PROCESS AND EARLY PATTERNING OR IMPRINTING MAY BE REVEALED DURING YOUR SESSIONS. (THIS WILL BE EXPLAINED IN MORE DETAIL). |
| PLEASE RELATE ANY INFORMATION YOU MAY HAVE REGARDING YOUR CONCEPTION: (PLANNED, WANTED, CONFUSED, UNWANTED) |
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| PLEASE CHECK WHAT YOU KNOW OR THINK APPLIES TO YOUR BIRTH HISTORY |
 AN UNMEDICATED VAGINAL BIRTH IN A HOSPITAL |
| AN UNMEDICATED VAGINAL BIRTH AT HOME |
| AN ANESTHESIA BIRTH |
| WITH FORCEPS |
| VACUUM EXTRACTION |
| WITH FETAL HEART MONITOR |
| C-SECTION |
| BREECH |
| A MULTIPLE BIRTH |
| PRIOR MISCARRIAGES (BEFORE YOU WERE CONCEIVED) |
| OTHER BIRTH COMPLICATIONS |
| IF CHECKED OTHER BIRTH COMPLICATIONS, PLEASE DESCRIBE |
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| PLEASE CHECK WHAT YOU KNOW OR THINK APPLIES TO YOUR PRENATAL AND BIRTH HISTORY |
| I HAD A TWIN THAT DID NOT LIVE |
| AT WHAT TIME IN THE PREGNANCY OR POST NATAL TIME DID THE TWIN LEAVE? |
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| I WAS PREMATURE |
| HOW MANY WEEKS? |
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| I WAS IN A NEONATAL INTENSIVE CARE UNIT |
| HOW LONG? |
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| I WAS IN AN INCUBATOR |
| HOW LONG? |
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| WAS YOUR FATHER PRESENT AT YOUR BIRTH? |
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WERE YOU SEPARATED FROM YOUR MOTHER AT BIRTH (SENT
TO A NURSERY)? |
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| WERE YOU BREAST FED? |
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| IF YES, FOR HOW LONG? |
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| PLEASE NOTE ANY INTERVENTIONS SHORTLY AFTER BIRTH SUCH AS HOSPITALIZATION FOR ILLNESS, OPERATIONS, ILLNESS AS AN INFANT OR A CHILD. |
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| WHAT DO YOU KNOW ABOUT YOUR LIFE IN THE WOMB? I.E PHYSICAL EFFECTS (MATERNAL OR PATERNAL SMOKING, DRINKING, DRUGS, MOM’S DIET) AND EMOTIONAL EFFECTS, INCLUDING ABSENCE/PRESENCE OF FATHER DURING PREGNANCY/BIRTH, PARENTS’ RELATIONSHIP, FAMILY TRAUMA? |
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| DO YOU OR DID YOU HAVE SIBLINGS? INDICATE AGES RELATIVE TO YOU, NATURE OF RELATIONSHIP AS CHILDREN. |
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| ADDITIONAL COMMENTS |
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PLEASE MAKE YOUR ANSWERS AS COMPLETE AS POSSIBLE. YOUR ANSWERS WILL HELP ME TO CUSTOMIZE YOUR SESSIONS TO YOUR GREATEST BENEFIT. THANK YOU.
PLEASE PRESS THE "SEND" BUTTON WHEN YOU ARE FINISHED FILLING OUT THE INTAKE FORM.
Dislcaimer: This treatment is not meant to take the place of allopathic medicine. If you have, or suspect you have, a health problem,or have questions about your individual medical situation, you should consult your physician or other qualified health-care provider. |
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