Mossage Client Questionnaire
This is an experience for you, in which your feelings matter. Help me understand what you are wanting so I can meet you in a way that is just right for you. If a question does not apply to you type "x".

When you complete this form I will be notified and usually respond and schedule you within 24 hours. Thank you!

Your full name:
Your answer
Name you prefer to be called:
Your answer
Please contact me by:
Required
Phone for calling:
Your answer
Phone for texting:
Your answer
Email:
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:
Genitals are always avoided. Examples: Breasts. Belly.
Your answer
Past issues and challenges still affecting me:
Please include traumas, injuries, skin conditions, and surgeries.
Your answer
The amount of pain I am comfortable with in this experience is:
The amount of pleasure I am comfortable with in this experience is:
I particularly like these kinds of contact:
Your answer
The professional dynamic I prefer is:
I prefer that the tone of our interaction be:
Examples: Serious. Supportive. Comforting. Celebratory. Cosmic. Fun. Etc..
Your answer
Some things you can do to help me feel comfortable:
Ask me how I feel. Let me be quiet. Make (or avoid) eye contact. Hold my hand. Allow me to speak first. Ask me what I might like. Remind me that this experience is for me. Remind me to express my preferences. Etc..
Your answer
Some experiences I would like to have here:
Examples: Feeling relaxed. Feeling safe. Feeling reset. Feeling good. Being treated as an equal. Being treated as if my feelings matter. Being asked what I want and what my preferences are, and getting them. Being comforted and supported without having to ask. Feeling cared for. Feeling intelligent. Feeling important. Feeling beautiful. Feeling natural. Feeling valued. Etc..
Your answer
I would like to work with you because:
Your answer
I would like help with:
Your answer
Some challenges I am currently facing:
Your answer
I have intentions for myself, and they include:
Your answer
Some actions I take regularly to improve my health and consciousness are:
Your answer
If I imagine myself totally happy, it looks like this:
Your answer
During the session I would like to feel:
Your answer
This work would be a total win for me if I left feeling:
Examples: Positive about myself. Exquisitely respected. Relaxed and comfortable. Grateful. Inspired to live more fully. Renewed in my trust in human goodness. Etc..
Your answer
Let's discuss my responses to this form:
I understand you work on a sliding scale, I am agreeing to pay at this rate.
I have a coupon code or discount and it is:
Your answer
I am committing to pay this much for this session:
Your answer
Ideally, I would pay this much, for a session this long, and get care this often:
Your answer
If I would appreciate a follow up call, text, or email after the session, I will put the details here:
Your answer
If I would appreciate a call, text, or email, inviting me to schedule another session, I will put the details here:
Your answer
If I have comments about this form or your site they are:
Your answer
If I have questions for you or about you, they are:
Your answer
I heard about you from a human, marketing item, or website, and it was:
Their name here:
Your answer
Thank you. PLEASE HIT THE SUBMIT BUTTON TO COMPLETE THIS FORM.
Thanks for your responses. Everything you entered here is confidential. When you hit the [submit] button you will be taken to a page with an email address that you can contact if I do not respond to you quickly. If I am on vacation that email address will reply to your message letting you know when I am due to return.
Your answer
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