Atma Prema Wellness Intake Form
This should take you 5 minutes or less to complete and must be completed prior to first bodywork session. Please answer these questions in full and to the best of your abilities and read my policy statement at the bottom of this form. If something does not apply to you, please answer "N/A".
Email address *
Personal Information
First and Last Name *
Phone Number *
Address where massage is taking place: *
Date of Birth *
MM
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DD
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YYYY
Occupation: *
Please list regular hobbies/activities:
Emergency Contact (Name, Relationship, Number):
Home Information
What type of property? *
Where should I park when I arrive? *
Please explain any stair / elevator information: *
Where will I set up my massage table?
Please list any pets you have:
Will anybody else be home during your session?
Massage Info & Preferences
When was your last massage? *
If you have received professional massage more than once, where did you go?
If this will be a prenatal massage, how far along will you be at the time of your session?
What areas do you want focused on in your session? *
Preferred Pressure: (click ALL that apply) *
Required
Is there anything you particularly enjoy or do not enjoy during massage? (i.e. I love face massage, I do not like my feet touched, I prefer not to talk during session) Or any particular requests for this massage? *
Are you interested in Palo Santo during your session? (small piece of aromatic wood, burned for a very short period as a way to clear energy/space ~ it is similar to sage/incense but a little more subtle)
Clear selection
What are your goals and expectations? (how do you want to feel DURING and AFTER your session) *
List any/all things you do for self-care AND how often (i.e. baths, rest, yoga, etc.):
Are you interested in self-care ideas/tips from me after your massage?
Clear selection
Is there anything else you would like me to know about you, your body, or your preferences? *
Health History
Please list all allergies or sensitivities you may have:
Please list any medical conditions you may have that you want me to know about:
Any recent (within the last 2 years) accidents, injuries, pain, or surgeries?
Additional
First & last name of who referred you (they will get a discount on their next session):
I have read 'How to Prepare for Your In-Home Session' and 'Atma Prema Wellness' Protocol for Reducing the Spread of Illness' (over at www.atmapremawellness.org) *
Preference on Face Mask Usage During Your Session (No judgement! Please choose what will bring you the most comfort during your in-home massage) *
How did you hear about me?
Clear selection
Please share anything else you would like me to know:
Policies and Acknowledgment By Client
By submitting this form, Client agrees to receive professional massage therapy services from Alexandra Strong, CMT (therapist). Client agrees that all information on this form is accurate and complete. Client agrees to inform therapist if any of the above information changes at any time. Client agrees to inform/communicate to therapist of any changes needed for comfort throughout session. Client agrees to inform therapist any time they feel their well-being is threatened or compromised. Client understands and acknowledges that Alexandra Strong is a Massage Therapist that provides strictly professional, ethical, and non-sexual massage therapy services. Client acknowledges that any sexual behavior by the client toward the therapist or by the therapist toward the client is unethical, inappropriate and unacceptable. Sexual harassment is not tolerated. If the therapist's or client's safety feels compromised, the session will be stopped immediately. Client has read and agrees to Alexandra Strong, CMT's payment and rescheduling policy. For more information visit www.atmapremawellness.org
A copy of your responses will be emailed to the address you provided.
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