Healy Session Intake Form

Please identify who you are scheduling this visit for. This person will be referred to as the Client for intake questions

Personal Information

Client Information (Adult)

Spouse Information (if applicable)

1. Child Information (if applicable)

If your minor child will be seeing a Practitioner, please fill out the following information for the client (your minor child).

By doing so, you are consenting that you are a parent or legal guardian and signatures will be signed by you, the adult.

2. Child Information (if applicable)

If your minor child will be seeing a Practitioner, please fill out the following information for the client (your minor child). 

By doing so, you are consenting that you are a parent or legal guardian and signatures will be signed by you, the adult.

3. Child Information (if applicable)

If your minor child will be seeing a Practitioner, please fill out the following information for the client (your minor child). 

By doing so, you are consenting that you are a parent or legal guardian and signatures will be signed by you, the adult.

Healy Session Intake Questionnaire

Email: tara@tarasplace.com or you may text the photo to 612-756-1800

Client Bill of Rights 

The following information is provided in accordance with the Minnesota Complementary and Alternative Health Care Freedom of Access Act, Chapter No. 460 – House File 3839. As of July 1, 2001, all complementary and alternative health care providers shall provide their clients with a copy of the Complementary and Alternative Health Care Client bill of rights. 

Reasonable accommodations shall be made for those clients who cannot read or who have communication disabilities and those who do not read or speak English. Please reach out to our team to request reasonable accommodations, contact information is below.     

Organization: Tara’s Place

Address: 1919 Conver Avenue
Phone Number: (612) 756-1800
Email:  tara@tarasplace.com 
Practitioner: Tara Steenblock

Practitioner Tara Steenblock

My name is Tara Steenblock and I have been a licensed massage therapist and a member of the American Massage Therapy Association since 2004. 

I can help support you with issues ranging from:

Reproductive health concerns, menstruation challenges, bladder conditions, digestive issues, chronic and acute muscle tightness, stress and headaches. I provide self care techniques for you to utilize in your life.

I love what I do and truly believe in a holistic, hands on approach.

Training and Certifications 

Graduate of Minnesota School of Massage 2004
Licensed Massage Therapist 2004
Certified  Abdominal Massage Practitioner - Arvigo Institute
Reiki Master & Teacher Certification
Gua Sha Trained
Certified Flower Essence Practitioner
Certified Flower Essence Practitioner
Certified Cupping Practitioner
Certified Nutritional Response Testing
Visceral Manipulation - Barral Institute - ongoing training
CranioSacral Therapy - Upledger Institute - ongoing training
Resonance Therapy - ongoing training

(in quotation marks) is required to be on the Client Bill of Rights in bold print by Minnesota statute 146A.11:  

"THE STATE OF MINNESOTA HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATION PURPOSES ONLY.  

Under Minnesota law, an unlicensed complementary and alternative health care practitioner may not provide a medical diagnosis or recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis from a licensed physician, chiropractor, or acupuncture practitioner, or services from a physician, chiropractor, nurse, osteopath, physical therapist, dietitian, nutritionist, acupuncture practitioner, athletic trainer, or any other type of health care provider, the client may seek such services at any time. ”

Tara’s Place accepts payment in full prior to service via electronic card services (payment by card). Fees for services vary according to the visit/session type, fees for service will always be provided prior to services. Tara’s Place does not accept health insurance.  

Clients have the right to reasonable notice of changes to prices, services, or policies. 

The clients’ practitioner will provide an assessment and recommended service that is to be provided during the Report of Findings visit. This visit may take up to 60 minutes and may result in the recommendation of a designed clinical nutrition program.  

Practitioners at Tara’s Place utilize the technology of muscle testing as a way to analyze dysfunction and toxicity of the body. 

Practitioners at Tara’s Place offer the following approaches through our programs:   

●Customized recommended solutions for the client’s unique needs based on muscle testing assessments to address the body’s dysfunctions and toxicities. 

●Ongoing support by re-assessing the client’s body’s unique needs through muscle testing, massage and providing adjustments to supplement and lifestyle recommendations based on the individual client body's needs. 

●Educating clients on a series of wellness principles including Nutrition Coaching/Nutritional

Therapy and Lifestyle Education, as well as empowering clients to optimize their own well-being. 

●Practitioners may use other modalities within their specialty, as needed, per the client’s unique physical, chemical, nutritional, and emotional needs. This may include Nutrition Response Testing (Muscle Testing for nutrition), Massage Therapy, Energy Therapy (REIKI) , and/or Healy (frequency technology to improve health and well-being). 

Clients have the right to complete and current information concerning the practitioner's assessment and recommended service that is to be provided, including the expected duration of the service to be provided. 

Clients may expect courteous treatment free from verbal, physical, or sexual abuse by the practitioner. 

Client records and transactions with the practitioner are confidential, unless release of these records is authorized in writing by the client, or otherwise provided by law. 

Clients have the right to be allowed access to records and written information from records in accordance with sections 144.291 to 144.298 

There are other practitioners who offer similar services available elsewhere. Information can be found by searching online for the services and modalities offered by our practitioners.  

Clients have the right to choose freely among available practitioners and to change practitioners after services have begun, as well as coordinated transfer when there will be a change in the provider of services. 

Clients may refuse services or treatment.  

Clients may assert their rights without retaliation.