Pediatric Massage Intake Form
Please fill out at least 48 hours prior to your appointment. If you have any questions please feel free to call or email, (518) 618-2298
. Thank you.
How did you hear about Creating Space?
Please mark your goals for your child's Pediatric Massage Program:
Reduct muscle hypertonicity
Improve muscle tone (decrease hypotonicity)
Improve gastrointestinal functioning
Improve joint mobility / range of motion
Promote orientation of extremities toward midline
Reduce chronic fatigue
Reduce colic / chronic abdominal pain
Improve self-soothing behavior
Improve attentiveness and responsiveness
Improve sleep patterns
Decrease hypersensitivity to touch
Enhance child's body awareness
Promote parent-child bonding
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