intake form

CROSSINGS CLIENT INFORMATION FORM

First Name

Last Name

Address

City

State

Zip

Home Phone

Cell Phone

Email Address

Date of Birth

Occupation

Emergency Contact

Emergency Contact Phone

Crossings Newsletter is an important way for us to stay in touch with you regarding any changes to our services and/or offerings. Would you like to receive the Crossings Newsletter?
YesNo

How would you like to receive Appointment Reminders?
TextEmail

Is there any discretion necessary when contacting you about your appointment time at home or work? If yes, please specify.

How did you hear about Crossings? Please specify.

Cancellation Policy: Most of our practitioners follow a 24 hour cancellation policy. Please reach out to your practitioner directly for specific details. Due to the reduced schedules for all practitioners please respect their treatment times that have been saved for you.