Ease the Shift - Intake Form

About You

First Name

Last Name

Email

Phone

Which transition best describes where you are?

Postpartum (within 2 years of birth) Perimenopause Menopause / Post-menopause Unsure / In between

Is this your first session at 5th Element Studio?

Yes, first time Returning client

What You're Experiencing

Hormonal transitions affect every system in the body. The more you can share, the better I can attune the session to what you're moving through right now.

Where does your body hold the most tension?

In your own words — what are you moving through right now?

How You're Feeling Today

Physical discomfort level

None

High

Emotional / nervous system level

Calm

High

What are you hoping to feel after today's session?

Health & Safety

Do any of the following apply?

Currently receiving treatment for depression or anxiety Pacemaker or electronic implant Recent surgery (within 6 months) Epilepsy or seizure disorder Active infection or open wound None of the above

Current medications or supplements (optional)

Anything else you'd like me to know?

Consent

Full Name (Signature)

Date

Ease the Shift
Session Intake

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