Effective Date: ___________________

Full Legal Name: ___________________________________________

Preferred Name / Pronouns: ________________________________

Date of Birth: __________________ Age: _______

Gender Identity: _________________________________

Address: ________________________________________________

City: __________________ Province: __________ Postal Code: ________

Phone: __________________________

Email: __________________________

Preferred Method of Contact:
☐ Phone ☐ Email ☐ Text

Emergency Contact Name: _______________________________________

Relationship: ______________________

Phone: __________________________

Parent/Guardian Full Name: ______________________________________

Relationship to Minor: __________________________________________

Phone: __________________________

Email: __________________________

☐ I confirm I am the legal parent/guardian and consent to services.

Signature: ______________________________ Date: _________________

What brings you to Zensations Health & Wellness Inc.?

What are your main wellness goals?
☐ Stress reduction
☐ Emotional regulation
☐ Pain or mobility support
☐ Nutrition guidance
☐ Fitness / movement
☐ Mindfulness / meditation
☐ Other: __________________________

Do you currently have or have you previously had any of the following?
(Select all that apply)

☐ Heart condition
☐ High blood pressure
☐ Diabetes
☐ Respiratory condition
☐ Chronic pain / injury
☐ Mental health concerns (anxiety, depression, PTSD, etc.)
☐ Trauma history (physical, emotional, sexual, or other)
☐ Allergies
☐ Pregnancy (current)
☐ Other: ______________________________

Optional Details / Triggers / Accommodations Needed:

You may share as much or as little as you feel comfortable.

Are you currently taking medications?
☐ Yes ☐ No

If yes, please list:

Are you taking supplements?
☐ Yes ☐ No

If yes, please list:

Do you currently exercise or engage in physical activity?
☐ Yes ☐ No

If yes, frequency and type: _____________________________________

Have you ever been advised by a healthcare provider to avoid certain movements?
☐ Yes ☐ No

If yes, please describe: ________________________________________

Optional: Please share any information about past experiences that may affect your comfort or participation:

Do you experience symptoms related to stress, anxiety, or trauma that you would like us to be aware of?
☐ Yes ☐ No

If yes, what strategies or supports help you feel safe?

Would you like to receive trauma-informed coaching, guided mindfulness, or grounding strategies during your sessions?
☐ Yes ☐ No

Sleep (hours/night): _________

Stress Level (1–10): _______

Occupation: __________________________

Tobacco / Alcohol Use: _________________________

Dietary preferences / restrictions:
☐ Vegetarian ☐ Vegan ☐ Gluten-Free ☐ Dairy-Free ☐ Other: ___________

Will you participate in virtual sessions?
☐ Yes ☐ No

I confirm:
☐ I have a safe, private space to participate
☐ I have the necessary equipment (mat, props, internet)
☐ I understand risks associated with virtual participation

Please initial each statement:

_____ I understand services are wellness-focused and not medical treatment.

_____ I confirm that the information provided is accurate and complete to the best of my knowledge.

_____ I understand I may disclose trauma-related information voluntarily and that I control how much I share.

_____ I agree to inform Zensations if my health or circumstances change.

_____ I have reviewed and signed the Liability Waiver & Parental Consent form (if applicable).

I understand that all personal and health information is collected, used, and stored in accordance with Canadian privacy laws and the Zensations Health & Wellness Inc. Privacy Policy.

☐ I consent

Signature: ______________________________ Date: _________________

☐ I consent to receive newsletters and promotional communications.
☐ I do NOT wish to receive marketing communications.

Practitioner Notes:

Program / Session Type: ________________________________

Follow-Up / Recommendations: __________________________

✅ TRAUMA-INFORMED NOTES / SAFETY STRATEGIES

• Use grounding exercises if needed.
• Offer control over pace and intensity of sessions.
• Provide opt-out options for exercises or topics that trigger.
• Avoid pressuring disclosure; allow voluntary sharing.