Mossage Preferences Form

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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

Name you prefer to be called: *

Gender *

Age *

18 - 29

30 - 39

40 - 49

50 - 59

60 - 69

70 - 79

80 - 89

90 - 99

Other:

Please contact me by: *

Phone call

Text

Required

Email: *

Phone: *

The session I want is: *

Reiki

Shiatsu

Mossage

Chair Massage

Other:

I prefer a session this long: *

One hour

Two hours (standard Mossage session)

Three hours (full body Mossage session)

Other:

The areas I want worked: *

Back and sides of body

Front and sides of body

Full body

Full body except breasts and belly

Other:

I feel most comfortable, empowered, and relaxed: *

Face up

Face down

On my side

Seated

Other:

Required

Please be sure these areas get attention: *

Examples: Feet. Hips. Shoulders.

Handle these areas with care: *

Examples: Left knee. Bruise on left shin.

Please avoid these areas: *

Examples: Breasts. Armpits. Face. [Genitals are always avoided.]

I like these things: *

Examples: Rub my head, scratch my back, pull my toes.

I want to feel this good: *

Mild -- relaxed and happy

Medium -- blissed out and speechless

Strong -- ecstatic and transcendental

Other:

The professional dynamic I prefer is: *

Passive: You mostly know what to do and do it.

Dynamic: We choose direction together, repeatedly.

Active: I mostly know what is good for me and ask you to do it.

Other:

I prefer that the tone of our interaction be: *

Examples: Chill. Friendly. Cosmic. Fun. Sweet. Kind.

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..

During the session I would like to feel: *

After the session I would like to feel: *

I would like to work with you because: *

I would like help with: *

My goals for this session are: *

Some other goals I have for myself are: *

Some actions I take regularly to improve my health and consciousness: *

If I imagine myself totally happy, it looks like this: *

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.

If I regularly use prescription medication or psychoactive substances I will tell you about them here: *

If I consider myself a heavy user of specific addictive substances or activities I will tell you about them here: *

If I have a history of psychological or emotional challenges or treatments, I will let you know about that here: *

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: *

Let's discuss my responses to this form: *

By phone, before the session

At the beginning of the session

I am requesting a house call and will pay a surcharge at this rate:

$20 Berkeley, North Oakland, Albany

$40 El Cerrito, Richmond, Oakland, San Leandro

$60 San Rafael, Tiburon, Mill Valley, Fremont, Sausalito

$80 San Francisco, Walnut Creek, Fairfax, Novato, Petaluma, Napa

$100 Palo Alto, San Jose, Sebastopol, Saint Helena

$120 Santa Rosa, Santa Cruz

No house call

Other:

Clear selection

For a good massage (1), great massage (2) or a massage that was one of the best experiences of my life (3) I would offer this much money (three answers divided by commas): *

Ideally, I would have sessions this long, this often and offer to pay this much: *

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).

Yes

Clear selection

Circumstances influencing this request:

(Examples: Homeless, Chronically Ill, Disabled, Student, Single Parent, Retired, Adult Dependents, Homeowner, Financially Independent)

If I have questions or comments for you, they are:

I heard about you from a human, marketing item, or website, and it was:

Their name here:

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 agree

I disagree

I need help with this

Clear selection

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.

I agree

I disagree

I need help with this!

Clear selection

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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