New Client form

“Healing By Water” with Spike Bywater

Aquatic Therapist | Certified ThetaHealing® Master and Teacher

Holistic Health Practitioner | Certified Massage Therapist

U.S. Navy Combat Veteran

Name

First Name

Last Name

Height

Weight

Phone Number

Numbers must contain only digits and no other characters.

Date of Birth

YYYY

Relationship Status:

Occupation:

Emergency contact:

Emergency Contact Phone Number

Numbers must contain only digits and no other characters.

Referred by

Military Status

Triple B Adventures member?

Please list any special health issues or requirements (health restrictions, surgeries, allergies, TBI or other serious health concerns and if required- information on emergency care and your doctor)

List any medications you are currently taking:

(Woman) Are you pregnant?

If yes, when is your due date?

YYYY

Please be specific in what areas you would like support in:

ie.: Body pain, joint pain, relaxation, spiritual development, letting go of attachments, experiencing something new etc.

Aquatic Bodywork Consent STATEMENT TO BE READ AND SIGNED BEFORE AQUATIC SESSION BEGINS

Are you allergic to bees?

YES

UNSURE

Do you require ear plugs?

Do you have any conditions that might be affected by being in warm water or be affected by stretching and moving, psychological conditions or trauma that might be affected by being held.

Previous experience with Aquatic Bodywork, Massage Therapy or Energy Healing?

Susceptible to motion sickness?

YES

Episodes of vertigo?

YES

Have you had any negative water experiences such as near drowning?

YES

If yes, please share:

Your eSignature (type your name)

Please read carefully: I understand that a session of any form of Aquatic Bodywork can be powerful and have profound effects, that when the body arrives at the level of relaxation possible in warm water and its normal tension holding patterns are released, there can, occasionally be reactions that can cause momentary discomfort. I also understand that being held as close as is required while being floated, can bring up issues that people have about intimacy. I will hold no one responsible for anything that happens to me during session. Ideally, the kind of heart space the session will help me into, and its continuity, will help me let go whatever comes up into its flow. I understand there have been no medical claims made for this session. I will give feedback the moment anything is uncomfortable. I understand that when I am brought to the end of the session, I am not required to immediately give feedback. I have read and agreed to the above statement and am listing above any conditions that might be affected by a session and agree to discuss with my practitioner:

Today's Date

YYYY

New Client form

Client Application

info@healingbywater.com • San Diego, CA