Selkie Inne
Nicole Tackaberry, LMT, MLD, CES EDS/Hypermobility Specialist
San Clemente, California
Section 1 of 8
1

Personal Information

Please enter your full name
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If someone referred you, I'd love to know who!

2

Primary Concerns & Goals

3

Hypermobility & Connective Tissue

Many of my clients have hypermobile or connective tissue differences — sometimes without knowing it. These questions help me understand your body better so I can work with it safely and effectively. There are no wrong answers.

Can you now (or could you ever) place your hands flat on the floor without bending your knees?

Can you now (or could you ever) bend your thumb back to touch your forearm?

As a child, did you amuse friends by contorting your body into strange shapes, or could you do the splits easily?

As a child or teenager, did your shoulder or kneecap dislocate on more than one occasion?

Do you consider yourself "double-jointed"?

If you're familiar with the Beighton score, feel free to note it here. If not, I can assess this at your appointment.

Hypermobility often travels with other conditions. Checking these helps me see the full picture.

Autonomic / Circulatory
Immune / Allergic
GI / Digestive
Neurological / Sensory
Structural
Pain / Fatigue
Other
4

Medical & Emotional History

Your history matters. Many people with complex conditions have had difficult experiences in healthcare. This section is here so I can understand your full picture — not just your symptoms.

This might include being dismissed, misdiagnosed, having pain minimized, or feeling unsafe. Sharing this helps me make sure you feel respected and heard here.

This may affect your comfort during bodywork, and sharing helps me approach you with care.

This helps me work safely with any contraindications or sensitivities.

Tell me anything that causes a reaction for you.

5

Your Preferences

6

Consent & Signature

Scope of Practice: Services at Selkie Inne include therapeutic massage, manual lymphatic drainage, corrective exercise, and Reiki. Nicole does not diagnose medical conditions or prescribe medication.
Your Right to Stop: You can pause or end your session at any time, for any reason, without explanation.
Communication: Please share openly about pressure, positioning, or discomfort. If something doesn't feel right, say so — your feedback guides the session.
Emotional Safety: Bodywork can sometimes bring up emotions. This is normal and welcome. You will never be judged here.
Confidentiality: Everything on this form and discussed in session is confidential.
After Your Session: Some soreness, fatigue, or emotional shifts are normal, especially with deeper work or lymphatic drainage. Drink water and rest as needed.
Minors: Clients under 18 require a parent or guardian present and signing below.
Please confirm that you've read the consent information
Please confirm the accuracy of your health information
Please confirm your consent to receive bodywork
Please provide your signature
Please select a date

Your form will be sent securely to Nicole at Selkie Inne.

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Thank You!

Your intake form has been received. I look forward to caring for you.

Reminder: Please arrive clean and fragrance-free. This helps ensure a comfortable experience for everyone, especially given sensitivities to scents and chemicals that many of my clients have.