Massage Intake Form

Wellness Intake Form

Please complete this form and review all policies at least 24 hours prior to your appointment. If you have questions please contact me at (973) 975-9625.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location Type*
Parking*
Do you have stairs at this location?*
Do you have pets at this location?*
Location notes (write "n/a" if not applicable)*
Date of Birth*
Occupation*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Name*
Emergency Contact Number*
In my commitment to providing a world-class massage experience to all of my clients and out of consideration for my time, I have adopted the following practices and policies:

BE READY
I travel to multiple clients throughout the day and appointments are scheduled accordingly. Please use the restroom, dress down to a robe (if you'd like) and be ready as soon as I am done setting up. Break down and set-up is not included in the session time, but consultations extending past 5 minutes do.

SPACE REQUIREMENTS
Please make sure the space intended for the massage session is clear. The massage table is 30 inches wide by 73 inches long. I require a minimum 3 feet of space around the entire table in order to perform the massage with ample room to move.

STAIRS
I kindly request that all sessions are on the first floor of the home unless other arrangements are discussed during booking.

MULTIPLE SESSIONS
Sessions performed back to back only require 2 minutes in between to change the table. Each client should be ready once the previous session is over.

INFORMED CONSENT
Prior to each massage session, the treatment plan will be discussed with you. During our consultation, you can specify the areas that you would like worked on, as well as areas that you would like me to avoid.

RESPECT FOR CLIENT NEEDS AND BOUNDARIES
I am happy to adjust pressure, temperature, music volume, work longer on an area or move on if you request it. Open communication is always encouraged.

CONFIDENTIALITY AND CONVERSATION
The discussion during your session is confidential. I am happy to have a conversation with you and share my professional expertise. You may also choose not to talk - the choice is yours!

DRAPING
A blanket and sheet will always be used to cover you and only the area being worked on will be uncovered. Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.

PETS
I love animals! I don't mind if pets are out and about, however if they're stepping around my feet, jumping on the table, or causing other distractions you may not enjoy the session as much, so it may be best to keep them in another room for the duration of the appointment.

PAYMENT
I accept cash, Zelle, or check. No credit cards. If paying through Zelle, please have the app downloaded on your phone and ready to send payment. Payment is due at the time of service before vacating the premises.

PEAK PERIOD
The following fees are applied during peak periods when demand is high.
7 PM - 9:30 PM = $30
Weekends = $50
Public holidays = 10%

CANCELLATIONS
To cancel an appointment, contact me directly at 973-975-9625. Cancellations via website or vagaro will not be received.

A minimum of 24 hours notice is needed to reschedule or cancel a massage. Appointments cancelled or rescheduled less than 24 hours prior to the session will be charged for the full session at my discretion.

ZERO TOLERANCE
Flow State Massage & Bodywork LLC has a zero tolerance policy. Requests for sexual activity will not be tolerated, will be viewed as solicitation, and reported to the proper authorities under the guidelines of the New Jersey Board of Massage and Bodywork. The session will end immediately, and if applicable, the remainder of the time will be forfeited. Full payment for the session will be collected and future appointments will not be permitted.

Please sign to indicate you have read and agree to the policies above.

Signature*
Yes, I understand the cancellation policy. Please sign below.*

Clear
The following information will be used to help plan a safe and effective massage session for you. Please answer the questions to the best of your knowledge.
Do you have any of the following symptoms? If yes, please contact me to reschedule your appointment.*

New and persistent coughShortness of breath/difficulty breathingFever (above 100 F)I have no symptomsOther
I understand that because massage therapy and bodywork involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19.*

I understand.
I understand that Cassara Grasso, LMT and Flow State Massage & Bodywork LLC cannot be held liable for any exposure to COVID19 or any contagion caused by misinformation on this form or the health history provided by the client.*

I understand.
I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless Cassara Grasso, LMT, and Flow State Massage & Bodywork LLC today and for all future sessions. I give my consent to receive treatment.*

I understand.
Have you had a professional massage before? If yes, how often?*
Do you have any allergies to oils, lotions, or ointments? If yes, please explain or write N/A.*
Do you have sensitive skin?*
Do you have any particular goals in mind for this massage session? (pain relief, relaxation, etc.)*
Please list specific areas you would like me to concentrate on during the session (if any):*
What kind of pressure do you like? (Light, Medium, Firm)*
What type of bodywork services are you interested in learning more about? Check all that apply, if applicable.

Performance StretchingFacial MassageRaindrop TechniqueCuppingCBD Massage
Would you like to include any of the following enhancements to your session?

Gua Sha Facial Massage (+10 minutes, +$25)Cupping (+$25)CBD Massage (+$25)Aromatherapy (+$15, choose from an uplifting or relaxing blend)
During a typical massage session I work on the following areas: scalp, pectorals, back, neck, shoulders, arms, hands, glutes, legs and feet. Are there any areas you DO NOT want worked on?*
Please indicate if any of the following apply:*

Joint DisorderOsteoporosisCancerBack/Neck ProblemsCarpal Tunnel SyndromeBlood ClotsRheumatoid ArthritisEpilepsyDiabetesFibromyalgiaTennis/Golf ElbowOsteoarthritis/TendonitisHeadaches/MigrainesDepression/AnxietyTMJDecreased SensationNumbness/TinglingPregnancyContagious Skin ConditionRecent accident or injuryArtificial JointSwollen GlandsHigh or Low Blood PressureOpen Sores or WoundsRecent FractureStrains/SprainsAllergies/SensitivitiesCirculatory DisorderBruises EasilyRecent SurgeryHeart ConditionVaricose VeinsNone of the aboveOther
Do you have any existing medical conditions? If not applicable, write "N/A"*
Are you currently under medical supervision?*
Are you currently taking any medications? If yes, what are they for?*
Is there anything else about your health history that you think would be useful for me to know to plan a safe and effective massage session for you?*
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
Signature*

Clear
Should be Empty:

Wellness Intake Form