New Client Intake Form
Please fill out the new client intake form, so I have a clear idea of what your body needs! To learn more about what to expect during your bodywork session, and to see if this kind of therapy is right for you, please visit my website here to learn more:
Email address *
What is your first and last name? *
Date of birth: *
Phone number? *
What is your preferred method of contact?
What is your occupation?
Please describe any goals you have for this session (ex: relax, gain more mobility in a stiff neck, relieve pain in the hip, learn pain coping techniques for birth) *
Please describe in detail the pain you feel and where you feel it: *
Please describe in detail any health conditions, allergies, or injuries there is a possibility you may have (ex: chronic pain that has suddenly gotten worse, bulging discs, broken bones, pulled muscles, tree nut allergy, etc) If none, please write "None": *
Please use this space to list any surgeries or implants I should be aware of before your session.
Are you currently on any medications? If so, what?
Are you currently pregnant or postpartum? (If yes, please answer the questions related to pregnancy and postpartum below)
Clear selection
Please describe the kind of pressure you prefer: *
Are you interested in: *
Where is your preferred setting for a massage? *
Please enter an emergency contact here (name and phone number) and your relationship to that person: *
Is there anything else you would like me to know before your session begins?
Pregnancy-Related Questions
Please skip the following questions if you are not pregnant.
What week of pregnancy are you currently in?
From whom are you receiving your prenatal care?
What goals do you have related to pregnancy and birth?
Are you working with any other alternative health/pregnancy care/birth workers during your pregnancy? (Example, prenatal chiropractor, acupuncturist, doula, Spinning Babies practitioner, etc)
Please list any complications you have experienced in your pregnancy.
Postpartum Questions
If you are not recently postpartum, please skip the following questions.
If you have recently had your baby, how many weeks postpartum are you?
Have you given birth via cesarean section in the last 8 weeks?
Clear selection
Are you currently breastfeeding and or pumping?
Clear selection
Do you feel like you experienced any trauma related to your birth? Feel free to include as little or as much as you're comfortable sharing.
Are you experiencing any postpartum depression or anxiety?
What else are you doing to support your well-being and healing process during this time?
Covid-19 Pre-Screening
In order to ensure the safety of all my clients, I will be assessing the risk level for each person I see before entering my office. If you feel like there is a chance you are currently infected or have been recently infected with Covid-19, please wait to come in for your bodywork session. There will be no penalties for canceled appointments due to sickness. Thank you so much for your honesty understanding during this time!
Do you have, or have you had, any of the following symptoms in the past two weeks? If none, select "none of the above." *
Do you work or volunteer in a healthcare setting? *
To the best of your knowledge, in the last 14 days have you... *
Please note the CDC recommends both client and practitioner to wear a mask throughout the entire session. *
I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By completing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner. Please write "Yes," your full name, and date. *
I have filled out the intake form to the best of my ability. Sarah is not responsible for the aggravation of any conditions that were present, and not disclosed verbally and in writing, at the time of the massage therapy session, which may be affected by massage. I will notify Sarah verbally and in writing if any changes in my medical profile occur, and understand that there will be no liability on Sarah's part should I fail to do so. If I experience pain, discomfort, or draping issues during the session, I will let Sarah know immediately so that the pressure/techniques/draping can be altered to my level of comfort. Please write "Yes," your full name, and date (: *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy