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Beth Mohr LMT. 513-713-6073

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Client Intake Form

Please fill out this form as best you can so we can establish the best care plan for you.
Please inform your therapist of any and all allergies

First Name

Last Name

Email

Phone Number

Previous/Current Health Concerns:

Stroke

Heart Attack

High/Low Blood Pressure

Blood Clots

Neuropathy

Headaches/Migraines

Arthritis

Cancer

Currently Pregnant

Plaease list any allergies/sensitivities:

Please help me to better understand your wellness goals and/or any areas of concern in the body:

Is there anyting else you would like your therapist to know before your session?

Date:

Your Signature

Thanks for filling out your Intake Form!

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