WI Child Intake Forms | Emily Klik LMT CST

Intake forms for Child / Pre-Teen clients in Wisconsin, age 4-12

Parent or guardian required to fill out intake forms and accompany minor client to sessions.

Please print and fill out the following 3 forms for your minor client's upcoming CranioSacral Therapy appointment: Intake WI Child 4-12, CST Informed Consent, HIPAA Consent

Intake WI Child 4-12.pdf

CST Informed consent.pdf

HIPAA Consent.pdf

If you are not able to print these forms in advance, no worries.

A blank set will be provided for you to fill out, upon your arrival to your appointment.

Having the forms filled out in advance will allow more time spent doing CranioSacral Therapy

during our scheduled session.

Please note this last form (called FYI HIPAA Notice of Privacy Practices) is for your information.

It does not need to be printed and signed.

FYI HIPAA Notice of Privacy Practices.pdf