You are here: Home › MFR Center Client Intake Form MFR Center Client Intake Form Please fully complete the Intake Form below before your first session (works best from desktop or laptop). If you experience problems with this online form, please download, print, and fill in this form and bring it to your first appointment” Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Cell Phone *United States +1United States+1United Kingdom+44Afghanistan+93Albania+355Algeria+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua & Barbuda+1Argentina+54Armenia+374Aruba+297Ascension Island+247Australia+61Austria+43Azerbaijan+994Bahamas+1Bahrain+973Bangladesh+880Barbados+1Belarus+375Belgium+32Belize+501Benin+229Bermuda+1Bhutan+975Bolivia+591Bosnia & Herzegovina+387Botswana+267Brazil+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria+359Burkina Faso+226Burundi+257Cambodia+855Cameroon+237Canada+1Cape Verde+238Caribbean Netherlands+599Cayman Islands+1Central African Republic+236Chad+235Chile+56China+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros+269Congo - Brazzaville+242Congo - Kinshasa+243Cook Islands+682Costa Rica+506Croatia+385Cuba+53Curaçao+599Cyprus+357Czechia+420Côte d’Ivoire+225Denmark+45Djibouti+253Dominica+1Dominican Republic+1Ecuador+593Egypt+20El Salvador+503Equatorial Guinea+240Eritrea+291Estonia+372Eswatini+268Ethiopia+251Falkland Islands+500Faroe Islands+298Fiji+679Finland+358France+33French Guiana+594French Polynesia+689Gabon+241Gambia+220Georgia+995Germany+49Ghana+233Gibraltar+350Greece+30Greenland+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea+224Guinea-Bissau+245Guyana+592Haiti+509Honduras+504Hong Kong SAR China+852Hungary+36Iceland+354India+91Indonesia+62Iran+98Iraq+964Ireland+353Isle of Man+44Israel+972Italy+39Jamaica+1Japan+81Jersey+44Jordan+962Kazakhstan+7Kenya+254Kiribati+686Kosovo+383Kuwait+965Kyrgyzstan+996Laos+856Latvia+371Lebanon+961Lesotho+266Liberia+231Libya+218Liechtenstein+423Lithuania+370Luxembourg+352Macao SAR China+853Madagascar+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania+222Mauritius+230Mayotte+262Mexico+52Micronesia+691Moldova+373Monaco+377Mongolia+976Montenegro+382Montserrat+1Morocco+212Mozambique+258Myanmar (Burma)+95Namibia+264Nauru+674Nepal+977Netherlands+31New Caledonia+687New Zealand+64Nicaragua+505Niger+227Nigeria+234Niue+683Norfolk Island+672North Korea+850North Macedonia+389Northern Mariana Islands+1Norway+47Oman+968Pakistan+92Palau+680Palestinian Territories+970Panama+507Papua New Guinea+675Paraguay+595Peru+51Philippines+63Poland+48Portugal+351Puerto Rico+1Qatar+974Romania+40Russia+7Rwanda+250Réunion+262Samoa+685San Marino+378Saudi Arabia+966Senegal+221Serbia+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia+421Slovenia+386Solomon Islands+677Somalia+252South Africa+27South Korea+82South Sudan+211Spain+34Sri Lanka+94St. Barthélemy+590St. Helena+290St. Kitts & Nevis+1St. Lucia+1St. Martin+590St. Pierre & Miquelon+508St. Vincent & Grenadines+1Sudan+249Suriname+597Svalbard & Jan Mayen+47Sweden+46Switzerland+41Syria+963São Tomé & Príncipe+239Taiwan+886Tajikistan+992Tanzania+255Thailand+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad & Tobago+1Tunisia+216Turkey+90Turkmenistan+993Turks & Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine+380United Arab Emirates+971United Kingdom+44United States+1Uruguay+598Uzbekistan+998Vanuatu+678Vatican City+39Venezuela+58Vietnam+84Wallis & Futuna+681Western Sahara+212Yemen+967Zambia+260Zimbabwe+263Åland Islands+358Which therapist are you seeing for your first appointment? *FrancesTomMichelleTabithaOlgaEricTanaTrevorKelleyBrandonOtherHow did you hear about us?YelpGoogleFacebookReferralOtherWould you also like to be contacted by Frances for a combo session of MFR w/Guided Meditation? This significantly enhances both the physical and emotional releases that come with Myofascial Release. *Yes, please.Not right now.Mailing Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth *(MM/DD/YYYY)Occupation *Gender *FemaleMaleOtherEmergency Contact Name *Emergency Contact Phone Number *Have you ever received a John Barnes style MFR Session? *YesNoI don't knowCommunication with your therapist during your session is essential. Will you agree to be willing to communicate anything you are feeling, whether physical or emotional, to your therapist? *YesNoUnsureWill you agree to daily fascia stretches as suggested by your therapist? *YesNoCurrent complaints/symptoms/issues: *History of Injuries (including adverse reactions from any COVID treatments or medications): *Any surgeries? *Any diagnoses (including long-COVID)? *Any conditions? *Please explain any emotional traumas which may be contributing to your conditions. *Bodywork Goals: *If you answer “yes” to any of the following questions, please explain as clearly as possible in the additional comments section at the end of the list.Do you frequently suffer from stress? *YesNoDo you have diabetes? *YesNoDo you experience frequent headaches? *YesNoAre you pregnant? *YesNoDo you suffer from arthritis? *YesNoAre you wearing contact lenses *YesNoAre you wearing dentures? *YesNoDo you have high blood pressure? *YesNoAre you taking high blood pressure medication? *YesNoDo you suffer from epilepsy or seizures? *YesNoDo you suffer from joint swelling? *YesNoDo you have varicose veins? *YesNoDo you have any contagious diseases? *YesNoDo you have osteoporosis? *YesNoDo you have allergies? *YesNoDo you bruise easily? *YesNoAny broken bones in the past 2 years? *YesNoAny injuries in the past 2 years? *YesNoDo you have tension or soreness in a specific area? Please specify in comments. *YesNoDo you have cardiac or circulatory problems? *YesNoDo you suffer from back pain? *YesNoDo you have numbness or stabbing pains? *YesNoAre you sensitive to touch or pressure in any area? Explain in comments. *YesNoHave you ever had surgery? Explain in comments. *YesNoAny other medical condition, or are you taking any medications we should know about? Explain in comments. *YesNoAdditional Comments: *Referred by:Consent to Treatment of Minor: By entering my name below, I herby authorize the therapist to administer bodywork techniques to my child or dependent as they deem necessary.BY CLICKING THE SUBMIT BUTTON BELOW, I AGREE TO THE FOLLOWING:I understand that the bodywork I receive is provided for the basic purpose of relaxation and release of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so the pressure and or strokes may be adjusted to my level of comfort. I further understand that bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialists for any mental or physical ailment of which I am aware. I understand that bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session should be construed as such. Because bodywork should not be performed under certain medical conditions, I affirm that I have stated all my own medical conditions and answered all questions honestly. I agreed to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.Send me a copy of my results!Send me a copy of my results!Submit