New Client Form

New Client Form

Balanced Bodywork with Kendrisa.
Filling out this form provides your therapist with the information needed to best assist you.

You will be contacted for a phone consultation within 24 hrs of completing the form.
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Reason for booking? (Check all that apply) *

I would like to relax and allow my mind/body to feel at ease. I have been feeling tension/pain in my body, and would like to feel relief. I experience anxiety and/or depression, and would like to see how massage therapy can benefit my emotional wellbeing. I would like to sleep better and/or more often. I am interested in learning about what a regular self care routine can do for me. I am celebrating a special time in my life. I am pregnant/recently had a child. Someone I care for has passed away. I recently had surgery. Other
Area(s) of focus for your massage therapy session? (Check all that apply) *

Scalp (Headaches) Neck Shoulders Elbows/Wrists/Hands Upper and Mid Back Low Back/Hips Quads/Hamstrings Knees Legs Feet/Ankles Other
Health Conditions (Check all that apply) *

High/Low Blood Pressure Arthitis Diabetes Depression Anxiety Insomnia Injury Surgery Pregnancy Cancer Heart Disease Headache/Migraine Joint Replacement Fibromyalgia None Stroke Blood clots Other
Which days of the week are best for your current schedule? (Select up to 3 options) *

Monday (9am - 2pm) Tuesday (9am - 6pm) Wednesday (10am - 7pm) Sunday (10am - 4:30pm)
Are you currently pregnant? *
How did you learn about Balanced Bodywork? *
This space is for any questions you have about massage therapy, or any information you would like to share before your appointment.
Read and sign the waiver below.

I understand that massage therapy is provided to aid the body in a positive way, but massage therapy is not able to treat/cure physical or mental illness.
If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure can be adjusted to my level of comfort.
I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
I understand that massage therapy and/or energy work are not a substitute for medical care.
I affirm that I have notified my therapist of all known medical conditions and injuries.
I agree to inform the therapist of any changes in my health and medical condition.
I understand that there shall be no liability on the therapist’s part should I forget to do so.
By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.
I Agree. *
Signature *

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Thank you for choosing Balanced Bodywork.
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New Client Form

Filling out this form provides your therapist with the information needed to best assist you.

Thank you for choosing Balanced Bodywork.