Thai Bodywork Client Intake & Consent Form

Thai Bodywork Client Intake & Consent
Full Name*

First NameLast Name
Address*

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Phone Number*

Area CodePhone Number
E-mail*
What is your date of birth?*
What is your height and weight?*
How did you hear about us?*
Other*
Do you have an allergy to a common house pet/dander? Or other pertinent allergies?*
Have you received a professional Thai Bodywork session before? How recently?*
HEALTH HISTORY:

Please note the following information will be used to help plan safe and effective bodywork sessions. It will be kept confidential. Please answer to the best of your knowledge.
Please note any surgeries, hospitalizations, accidents (like falling from a horse), broken bones or sprains, stitches and scars, medications, and supplements in the space below.*
Do you experience daily pain in your body? Where?*
Please select any of the following conditions if they may apply to you:*

anxiety and/or stressvaricose veinsdepressionhigh or low blood pressureblood clotsdiabetesartificial jointheart conditionseasy bruisingcirculatory issuesTMJheadaches/migrainesnumbnessrecent surgeryrecent injurypregnancy or wish to become pregnantmenstruating currently/on day of our sessionosteoporosisepilepsy/seizuresfood allergy/sensitivityarthritisfibromyalgianone of theseOther
Tell me about a typical day: What motions/gestures does your body make regularly at work? What is your work? Are you sitting at a workstation, computer, or driving for many hours?*
What movement and gestures are you doing on a typical day off work?*
Please tell me about your exercise & frequency:*
What are your hobbies?*
What is your living situation? Do you live alone? What is your peer group like?*
Describe below your caffeine, alcohol, tobacco, other drugs, and plant medicines usage below:*
How do you sleep? Length/quality/dreams.*
Let's talk about your digestion and assimilation of nutrients.Typical food intake: Breakfast, Lunch, Dinner, and Snacks*
How much water do you drink on an average day in ounces?*
Digestion – are you typically hungry? Do you have regular bowel movements?*
Session Expectations
Do you have any restrictions of movement due to past injury? Where?*
Are there any stretches or yoga postures that may be harmful? Where?*
What are your likes and dislikes in massage or bodywork sessions?*
Treatment Requests: What 3 specific body areas would you like to have focused on during your session? Are there any emotional or mental concerns needing focus?*
Do you have any other goals for the session?*
Please read the following terms thoroughly.
Cancelation Policy

Remember, your appointment time is TIME RESERVED JUST FOR YOU.
If you anticipate missing your scheduled appointment with less than 24 hours notice, for any reason — including but not limited to illness, injury, a sick child, traffic, weather conditions without a severe weather warning, job-related conflicts, and family emergencies — please contact Jess immediately. This allows the opportunity for someone else to schedule during that time.
Cancellation without 24 hours or more notice prior to your scheduled appointment time, or "no-shows," will incur a full session rate charge invoiced to you.

Booking Your Session

Jess customizes sessions for the individual, and as such, scheduling with her directly is best. Contact her via phone or email to schedule your bodywork or yoga session.
Her working hours are typically daylight hours only, Monday through Saturday. Some exceptions may be made.
It is best to allow spaciousness after your bodywork session to best integrate. In other words, please do not schedule yourself to have to go right into work and be in a mentally charged headspace right after your session.

Pricing

Bodywork, yoga, and breathwork are not one-time cure alls, just like getting one chiropractic adjustment, one physical therapy session, or one pill from a bottle of prescribed medication isn't either. These sessions are best incorporated in your ongoing self-care, and by working with Jess you will have an accountability partner to help you create lasting change.

Jess offers session rates for 1-time purchasers or for those wishing to package many sessions together. Consider pairing yoga, breath, meditation, and mindfulness practices with your bodywork sessions! Or, consider having weekly bodywork plus her insight in creating home stretching and breathing routines. There are numerous possibilities.

Jess's rate is $150 per hour with a 2 hour minimum; when multiple sessions are packaged together or when a client refers friends and family, Jess is able to offer discounts. There are a few times each year where Jess is able to offer discounts or sliding scale to her usual rate.

Payment Methods & Expectations
- Payments can be made by:
  - Cash or Check
  - Electronic Payment
  - Online Credit or Debit card
- Payment is due at time of service. Pre-payment for a series or package of sessions is encouraged but not required, and a "pay as you go" method is just fine.
Gratuity?

While not expected, any gratuity added during payment will be appreciated. Jess uses additional gratuities to help offset rental costs for studio space and for continuing education trainings and certifications.

Clothing

Thai Bodywork is a practice done fully clothed. It is recommended that you come to your session wearing clothes that you can move around in easily, like what you would wear to a yoga class or to the gym.
Receiving bodywork will often cause the body to relax, much like going to sleep at night, and thus you may get cold. Please plan accordingly and wear or bring a long sleeve or warmer pants and socks. Jess will have an extra blanket should that be needed.

As you might expect, yoga and breathwork are practices which require ease of movement as well. Always come prepared to move freely.

Food & Drink before receiving Bodywork or Participating in Breathwork

The digestive system is one of the most energy consuming processes of the body: avoid eating a full meal within at least 2 hours of your session start time. It is better to be a little hungry by the end of the session.
Drink more water than your usual on the day of your session. Hydration is key for fascia to be mobile!

What to Expect during your Bodywork Session
- Every bodywork session is different. Jess offers an individualized and intuitive approach, and each client will experience it differently.
- Sessions begin with time discussing your client intake form (for first time visits) or with sharing what is pertinent in your body/mind/spirit that day. There is always about 30 minutes of time split before and after cushioned into the session duration for this connection time. Jess will listen to your speech and your body to learn how best to cater your session.
- Jess may offer guidance or suggestions, but remember - she is not a doctor. Anything offered is merely for educational and self-growth purposes and it is up to you what you would like to do with those recommendations.
  The duration of the bodywork portion of the session will include a variety of techniques: muscle compression, joint mobilization, assisted yoga-like stretches, energy work, fascial releasing techniques, and conscious breathing. You may be lying on your back, on your belly, on your side, or sitting upright cross-legged.
- Jess's work has been said to help the receiver to "ground their consciousness in the present moment."
- The only tasks you have as a receiver of Thai Bodywork are:
  - Surrender, melt, offer no help as Jess moves you around
  - Breathe fully, deeply, and consciously for the entire session
Benefits of Regular Bodywork

Receiving bodywork regularly can creating lasting change for your life. Some possible benefits are:
- improved circulation and blood oxygenations
- deeper breathing and improved lung capacity
- improved posture
- increased flexibility & released chronic muscular tension and pain
- better sleep and faster healing of injured muscular tissue
- reduced anxiety, depression, and blood pressure
- reduced mental and physical fatigue and stress
- increased self-love and compassion
- a more centered mind and body
Suggested Frequency of Bodywork

This will really depend on the person and their condition. In general, Thai Bodywork is not a one-time fix, especially if you have any ongoing circumstances. Most people find it difficult to remember good self-case, especially when they are stressed.

PROBLEM SPECIFIC: If you need focused work done, bodywork every 1 to 2 weeks will help you make progress quickly.
REGULAR SELF-CARE: Bodywork 2 to 4 weeks or so will help keep yourself in optimal shape (along with a balanced lifestyle, nutrition, and regular exercise).
CHRONIC CONDITIONS: If you want to address an ongoing issue and make quick progress, you might benefit from a weekly bodywork session for a couple months, depending on the issue.
CONSENT
I understand that bodywork includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body and discontinue the activity. I assume full responsibility for any and all damages, which may incur through participation. I understand also that "results will vary" from session to session and client to client.

Bodywork is not a substitute for medical attention, examination, diagnosis or treatment. Bodywork is not recommended and is not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in such a fitness program.

In addition, I will make the practitioner aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am postnatal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice bodywork and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against practitioner Jess Crutchfield and business Infinite Within LLC.

Participation in private bodywork sessions includes possible exposure to and illness from infectious diseases including but not limited to COVID-19, MRSA, and influenza. While Jess Crutchfield will never lead a session if showing symptoms, the risk of serious illness does exist. I knowingly and freely assume all risks, both known and unknown, and assume full responsibility for my participation.

I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe any unusual or significant hazard during my presence or participation, I will remove myself from participation. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release and hold harmless Jess Crutchfield with respect to any and all illness, disability, death, or loss or damage to person or property, to the fullest extent permitted by law.

I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law in the state of Colorado.
Electronic Signature (full name) to consent to these terms:

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Thai Bodywork Client Intake & Consent

HEALTH HISTORY:

Session Expectations

Please read the following terms thoroughly.

CONSENT