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Mossage Preferences Form
By filling in this form thoughtfully and sincerely you help me understand how to serve you well, and interact with you in a way that empowers you.
Your name: *
First name and last name
Your answer
Name you prefer to be called: *
Your answer
Gender *
Your answer
Age *
Please contact me by: *
Required
Email: *
Your answer
Phone: *
Your answer
The session I want is: *
I prefer a session this long: *
The areas I want worked: *
I feel most comfortable, empowered, and relaxed: *
Required
Please be sure these areas get attention: *
Examples: Feet. Hips. Shoulders.
Your answer
Handle these areas with care: *
Examples: Left knee. Bruise on left shin.
Your answer
Please avoid these areas: *
Examples: Breasts. Armpits. Face. [Genitals are always avoided.]
Your answer
I like these things: *
Examples: Rub my head, scratch my back, pull my toes.
Your answer
I want to feel this good: *
The professional dynamic I prefer is: *
I prefer that the tone of our interaction be: *
Examples: Chill. Friendly. Cosmic. Fun. Sweet. Kind.
Your answer
Some things you can do to help me feel comfortable and communicate with me well: *
Examples: Talk to me reassuringly during the session, reminding me that this experience is for me. Let me be quiet. Check in with me regularly using simple hand-squeeze signals to assure that I am comfortable. Remind me not to endure anything. Assure me that you will not be hurt by me sharing preferences or making requests. Remind me that you want to give me an experience that is exactly right for me. Let me direct you and ask for what I want. Tell me what you plan to do and let me say yes or no. Etc..
Your answer
During the session I would like to feel: *
Your answer
After the session I would like to feel: *
Your answer
I would like to work with you because: *
Your answer
I would like help with: *
Your answer
My goals for this session are: *
Your answer
Some other goals I have for myself are: *
Your answer
Some actions I take regularly to improve my health and consciousness: *
Your answer
If I imagine myself totally happy, it looks like this: *
Your answer
Some issues and challenges I have experienced or am working with that might be important to know about if working with me: *
Please include traumas, psychiatric episodes, injuries, self-harm, skin conditions, and surgeries.
Your answer
If I regularly use prescription medication or psychoactive substances I will tell you about them here: *
Your answer
If I consider myself a heavy user of specific addictive substances or activities I will tell you about them here: *
Your answer
If I have a history of psychological or emotional challenges or treatments, I will let you know about that here: *
Your answer
If I have experienced damaging, unwanted, confusing or conflicted touch or connection, experienced sex addiction or love addiction, or have little experience with emotionally connected touch, I will tell you about them here: *
Your answer
Let's discuss my responses to this form: *
I am requesting a house call and will pay a surcharge at this rate:
For this particular session I would like to share this much time and offer this much money: *
Your answer
Ideally, I would have sessions this long, this often and offer to pay this much: *
Your answer
I am requesting to pay on the low-income, low-asset sliding scale (and I understand that to qualify I must have both income below $50K/year and assets less than $25K or some huge burden that I will mention).
Circumstances influencing this request:
(Examples: Homeless, Chronically Ill, Disabled, Student, Single Parent, Retired, Adult Dependents, Homeowner, Financially Independent)
Your answer
If I have questions or comments for you, they are:
Your answer
I heard about you from a human, marketing item, or website, and it was:
Their name here:
Your answer
I understand that taking psychoactive herbs, drugs or medications, including alcohol and marijuana, affects my ability to communicate, and affects your ability to accurately interpret my body’s signals. I commit to coming to the session unmodified by such substances for at least 24 hours, and ideally 72 hours (or in the case of prescription medications, telling you about them in the space above). And I commit to telling you about any strongly psychoactive substance I have used in the previous two weeks, or that I feel still affects me, at the beginning of the session, so that you can factor that into treating of me.
I understand that you, the therapist, are here to help me relax and to help me feel good. I understand that you, the therapist, can notice if my body is relaxing and if I seem to feel good, but cannot know if I am comfortable with how much I am relaxing or with how good I feel. I understand that you use both voice and hand signals to assure that I have a wonderful, empowering experience. I commit to using them with you, and to helping you understand my challenges around communicating, so that our work together is successful.
Thank you for completing this form. HIT THE SUBMIT BUTTON NOW AND MAKE SURE IT TAKES YOU TO ANOTHER SCREEN.
Thanks for your responses. Everything you entered here is confidential. You can see my availability and book an appointment using the [Book Now] button at www.mossage.info.
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