Massage/Reiki Intake Form

Massage/Reiki Intake Form

Amy's Healing Arts
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Birth Date

MonthDayYear
Gender

MaleFemaleOther
Emergency Contact:

First NameLast Name
Emergency Contact Phone Number:
Please enter a valid phone number.
DO NOT CLICK THIS BOX UNLESS YOU ARE GIVING CONSENT FOR AN UNDERAGE CLIENT ONLY:

I am the parent or guardian of the client, who is under the age of 18, and by clicking the box I give permission for them to receive the chosen Reiki or Massage or Hypnosis modality.
Choose the Services you are having today:

MassageReiki
Occupation: (This tells me what you do with your muscles all day.)
What are your goals for receiving Massage or Reiki?

Pain reliefRelaxationAddressing a traumaStress reductionDeep Pressure, release knotsSpecific Issue/ area of concernOther
Choose symptoms you're experiencing today:

painSorenessStiffnessDizzinessSwellingNauseaNumbnessTingling
Please Choose all that apply to ensure a comfortable and safe Session:

Sensitive to TouchSensitive to FragranceHad Reiki session beforeHad Massage beforeCurrently under care of a physicianAllergy to lotions/oilsAllergy to Essential oilsHistory of Seizures
For Females:

Pregnant1st Trimester2nd Trimester3rd Trimester
Are there any injuries, accidents, surgeries, Illness, or recent health conditions that I should be aware of?
Please list any Major Medications or if you use topical hair grow serum:
Rate of Pain 1 to 10: (10 being Max)
Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • Please turn off or place your cell phone on silent for optimal relaxation.

• 24-hour cancelation notice is required to avoid being charged for your session.

       • You will be fully covered & draped at all times and at no point will genitalia or breast tissue be exposed.

       • You will have a consultation with your therapist to discuss your session.

       • Should the session require, you may disrobe to your comfort level and position yourself properly under the sheets only after the therapist has left the room.

       • Inappropriate behavior will not be tolerated and may be prosecuted to the fullest extent of the law

Client Agreement:

I understand that therapeutic massage therapists do not diagnose illness or disease, any physical or mental disorder, nor do they prescribe medical treatment, or pharmaceuticals.

Acknowledgments:

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive a therapeutic massage as a form of therapy.

I understand that my massage therapist or I may end the session at any time for any reason and full payment is due.

I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they may adjust.

I have stated my pertinent medical conditions and will update the massage therapist of any changes in my health status. I understand that my failure to do so may pose a threat to my health and/or physical well-being and I hold harmless Amy's Healing Arts and my massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.
REIKI

I understand that Reiki is a simple & gentle, hands-on Energy technique that is used for stress reduction and relaxation to align the subtle energy systems within our bodies and contributes to a balanced physical, mental, emotional, and spiritual well-being.

During a Reiki session, your Reiki practitioner may place their hands on or just above your body in a series of hand positions to deliver Reiki energy.

I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed healthcare professional for any physical or psychological ailment I may have.

I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and I acknowledge that long-term imbalances in the body sometimes require multiple sessions in order to do.

If you experience any pain or discomfort during this session, immediately inform the practitioner.
Please sign below if you acknowledge the given information and give your consent to receive the treatment.

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