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Please fill out this intake and email it back before our 1st appointment.

Intake Form

  • 6. Rate your level of satisfaction in the following areas on a scale of 1 (low) -10 (high):
  • Disclaimer and Consent:   By doing this work with Sarah Martin you will be introduced to her healing methods which were developed from her trainings and her personal experiences. Her programs are designed to help you heal underlying causes to your pain and life circumstances. She offers her services as a kinesiologist, energy medicine practitioner, healer, body worker, massage therapist, and mentor. She is not a licensed physician, psychologist, mental health counselor, or health care provider. Her services are not licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code. Sarah Martin can offer you her services, subject to the requirements and restrictions that are described fully therein. She strongly advises that you seek professional advice as appropriate before making any health decision. In consideration of my participation in healing work with Sarah Martin, I for myself, my heir and assigns, hereby release Sarah Martin from any claim, demands and cause of action arising from my participation with her work. It is my understanding and I have been informed that there exists the remote possibility during exercise of adverse changes including, but not limited to, abnormal blood pressure, fainting, dizziness, disorders of heart rhythm, and in very rare instances heart attack, stroke, or even death. I further understand and I have been informed that there exists the risk of bodily injury including, but not limited to, injuries to the muscles, ligaments, tendons, and joints of the body. Every effort, I have been told, will be made to minimize these occurrences by proper assessments of my condition before each movement training session, supervision during exercise and by my own careful control of exercise efforts. I fully understand the risks associated with exercise and energy work, including the risk of bodily injury, heart attack, stroke or even death, but knowing these risks, it is my desire to participate as herein indicated. I am aware that unforeseen complications may arise during these activities. I agree to assume full responsibility for my participation and hereby consent to participate. I fully understand that I may injure myself as a result of my participation in Sarah Martin’s treatment program and I hereby release Sarah Martin from any liability now or in the future. Sarah Martin is absolved from any claim or liability whatsoever and for any damage or injury, personal, financial, emotional, psychological or otherwise, which I may incur arising at any time out of or in relation to my use of the information presented in this program. If any court of law rules that any part of the Disclaimer is invalid, the Disclaimer stands as if those parts were struck out. I understand that the treatment I receive is provided for the basic purpose of healing. If I experience any pain or discomfort during this session, I will immediately inform Sarah so that the treatment can be adjusted. I further understand that sessions should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that Sarah is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any mental illness, and that nothing said in the course of the session given should be construed as such. Because sessions should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep Sarah updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.