Selkie Inne
Nicole Tackaberry, LMT, MLD, CES Lymphatic & EDS-Informed Specialist
San Clemente, California  ·  (909) 453-7386  ·  Mon & Wed 9:30am–1:30pm  ·  Thu & Fri 9am–3pm
Section 1 of 7
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Personal Information

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If someone referred you, I'd love to know who!

2

Primary Concerns & Goals

Tap to place a marker or draw to trace scar locations. This helps Nicole prepare for your session.

FRONT BACK
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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

Lymphatic Flow, Concussion & Vision

Concussion History

Binocular Vision & Visual Symptoms

Vision, balance, and eye symptoms are often connected to lymphatic congestion in the upper watershed — the region of the head, neck, and upper chest where lymph drains last. Concussion history, brain fog, light sensitivity, and tracking difficulties can all reflect stagnation in this area. These questions help Nicole identify whether upper lymphatic work should be a priority in your session.

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Your Preferences

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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.

✓

You're All Set

Your intake has been received and will be reviewed before your session. Nicole will reach out if she has any questions. You do not need to bring a printed copy — this is all she needs.

Before Your Session

  • 🚿  Please arrive freshly showered or bathed
  • 🌿  Arrive fragrance-free — no perfume, cologne, scented lotion, or heavily scented hair products
  • 🧴  Skip deodorant if possible, or use an unscented option — many clients with MCAS or sensitivities are affected by fragrance in close contact
  • 👗  Wear comfortable, loose clothing you can easily change out of
  • 💧  Hydrate well before and after your session — especially important for lymphatic work
  • 🍽️  Avoid a heavy meal in the hour before your appointment
  • 📵  Plan to arrive calm — give yourself a few minutes in the car before coming in

Cancellation & Rescheduling Policy

A minimum of 48 hours' notice is required to cancel or reschedule your appointment without charge. Cancellations made within 48 hours of your scheduled session will be subject to a 50% late cancellation fee. Same-day cancellations and no-shows are charged the full session rate.

Life happens — if you are experiencing a genuine emergency, please reach out directly at (909) 453-7386 and Nicole will work with you.

Payment

Payment is due at the time of service. Selkie Inne accepts all major credit and debit cards via Square, as well as cash. Packages and programs are paid in full at booking.

Selkie Inne is a space built for bodies that have been hardest to understand. You are welcome here exactly as you are. Nicole looks forward to meeting you.