New Client Intake Form

New Client Intake Form

If you are booking your first appointment with me, please take a moment to complete the intake form below, or download it and bring it in with you. The questions on the form will provide a comprehensive view of your condition(s)/ complaints and help tailor a treatment plan to best help you.

I also ask that you review my cancellation/rescheduling policy, which I will have you sign a copy of in my office, so we are on the same page.

Thank you, and I look forward to meeting you!

MASSAGE THERAPY CLIENT INTAKE FORM

    I will sometimes text to remind you of your appointment or to reschedule if I have a conflict.
  • Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.

    All client information is strictly confidential. The information you provide on this intake form is used only by me to better understand and serve the needs of my client. Furthermore, the Texas Department of State Health Services requires a consultation/intake form on every massage client.

  • I, the undersigned, understand and acknowledge that payment for all care received is my responsibility. Payment is due at time of services unless other arrangements have been made in advance with the massage practitioner. Skillful Touch Massage accepts cash or checks. I also understand that a 24-hour rescheduling notice is necessary to avoid charges.
  • I, the undersigned, understand that the massage/bodywork I receive is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

    I have received a copy of the therapist’s policies, I understand and agree to abide by them.