New Client Intake Form

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No plan of care established

Email *

Name: *

Phone Number: *

Session Date: *

YYYY

Session Location Preference: *

Indoors

Outdoors (weather permitting)

Session Type (check one): *

Somatic (75 min)

Swedish (75 min)

Deep Tissue (75 min)

Deep Stretching (30 min)

Required

Target area(s): *

Do not touch area(s), if none enter n/a:
*

Choose your desired aromatherapy blend (coconut oil base): *

Zenergy (lemongrass, bergamot & matcha)

Balance (palo santo, pineapple & clary sage)

Refresh (eucalyptus, peppermint & spearmint)

Serenity (lavender, hemp & chamomile)

Lovespell (blackberry, rose & raspberry leaf)

Intimacy (sandalwood, mahogany shea & myrrh)

Ecstasy (sweet orange, mangosteen & grapefruit)

Tranquility (teakwood, sea salt & aloe)

Rooted (frankincense, cedarwood & vetiver)

None

Optional add-ons: *

Soft Stretching Post-Massage (free)

EFAC Pain Relief Cream Usage ($10)

Required

Health History (check all that apply) *

Pregnant

High blood pressure

Diabetes

Circulatory issues

Recent surgery or injury

Joint or muscle pain

Skin sensitivities or allergies

Seizures or neurological conditions

N/A

Other:

Required

Current medication(s), if none enter n/a:
*

Financial Acknowledgment:

To maintain clear expectations and uphold the energy exchange of our work together, please review and acknowledge the following by checking off each statement.

A nonrefundable deposit is required at the time of booking to reserve your session.

Deposits may be transferred to a different date with appropriate notice.

The card on file used for your deposit will be automatically charged the remaining balance after your session unless another form of payment is clearly communicated prior to session end.

If your card on file is no longer valid (expired, declined, etc.), you agree to notify us prior to session start and provide an alternative method of payment.

Required

Timeliness Acknowledgment:

To maintain clear expectations and uphold accountability on both ends, please review and acknowledge the following by checking off each statement.

Cancellations must be made at least 24 hours in advance of your scheduled session.

Same-day cancellations will result in a charge of 50% of the remaining session balance.

No-call/no-shows will be charged the full remaining balance and may affect future booking privileges.

Each session includes a buffer for client-practitioner check-in, cool down and set up/take down.

Sessions begin and end on time. If your session start time is delayed due to any circumstances outside of the practitioner’s responsibility, your appointment will continue for the remainder of the originally scheduled session only.

If time allows, session extensions may be offered at the discretion of the practitioner.

Required

Media and Content Release:

The practitioner may occasionally document elements of client sessions to share the spirit of healing and somatic wellness through educational and creative platforms. Your privacy and consent are always a priority and all media will be appropriate either with client facing down and/or clothed appropriately.

I give consent for the practitioner to capture and share visual, written, or audio content from my session to use on digital or print platforms.

I do not give consent for any media content from my session to be recorded or shared.

Client Acknowledgement:

To maintain clear expectations, meet legal requirements and uphold accountability on both ends, please review and acknowledge the following by checking off each statement.

I have disclosed all relevant health information & understand I can end the session any time.

Any inappropriate behavior, including suggestive language or conduct, will result in immediate termination of the session with full payment still required.

I give consent to receive these services voluntarily and understand the nature of the work being performed.

The practitioner is currently enrolled in massage therapy school and is not yet licensed in the state of Wisconsin.

The session I receive today is for personal wellness, relaxation, and energy alignment and is not a replacement for medical care.

Required

Emergency Contact (name and number) *

A copy of your responses will be emailed to the address you provided.

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