Steven Townsend LMT Consultation Form

Steven Townsend, LMT

Relief, Recharge and Radiate!

Caddo Office Reimagined

6401 Eldorado Pkwy Suite 320, McKinney, TX 75070

2060 N. Collins Blvd Suite 109, Richardson, TX, 75080

www.StevenTownsendMassage.com | StevenTownsendLMT@gmail.com

972-365-3820 (call or text)

Name*

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Email*

Your Birthday*

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How often would you like to receive massage therapy?

What is more important to you?

Whole Body Massage:

The areas of the body to be massaged are referred to as 'Whole Body.' This includes the Neck, Back, Shoulders, Arms, Legs, Pectorals, Hips/Gluteals, Feet and Hands.

Please select the areas of the body you would like focused therapy on.

Please select the areas of the body you would like avoided.

Medical History: Provide a complete list of all medical conditions, including past injuries and surgeries.

Are you currently pregnant?

Please list any car accidents.

Please List any Sexual Transmitted Diseases:*

Do you currently have Cancer? (if yes please explain)

What is your Level of Exercise

Please provide a list any vitamins/supplements or prescription medications you are currently taking

Have any additional thoughts or details? I’d love to hear anything that can help make your session perfect.

Massage is for the sole purpose of stress reduction, relief from muscle tension, muscle spasms and to increase circulation. Massage Therapists do not diagnose or prescribe, nor is massage a substitute for medical examination of a person's physical or mental health. Please consult a physician for any medical concerns.

If my health history or any of the information on this form changes or the reason for receiving massage changes, you must update me with a new consultation form before your next treatment.

Your feedback is essential to provide you with the best massage experience possible. If you or your therapist becomes uncomfortable for any reason during the massage session either person can request the massage to end.

With massage I use a draping method that includes: Covering the body with a sheet or towel, only uncovering the part of the body being massaged.

Massage can Not be provided if you have a contagious virus, Flu or Cold, Cancer, or if you are under the influence of Alcohol or illegal Drugs, a contagious or spreadable disease, and poison ivy or poison oak. It's also not uncommon to have some soreness or even bruising after a therapeutic massage session.

Fragrance-Free Policy: I ask for all clients to refrain from wearing strong perfume, cologne, after-shave, scented lotions, body sprays or other similar products and not to smoke right befoe your treatment on the day you vist.

Sickness Policy: I kindly ask that you reschedule your appointment as soon as you are aware of an infectious or contagious condition, you feel sick, currently have or been currently exposed to COVID. If you arrive for your appointment with symptoms of an illness, you will kindly be asked to reschedule your appointment to avoid the spread of germs or make your condition worse.

Client Confidentiality

Client confidentiality during a massage session is of utmost importance. Therapists follow stringent privacy protocols, ensuring that any personal information disclosed by the client remains strictly confidential. This means that everything discussed during the therapy session stays private and is not divulged to anyone else without the client's explicit permission. This includes not disclosing information with family, friends, or other professionals unless authorized by the client, thereby creating a safe and trustworthy environment for all discussions during the session. Therapists also maintain discretion regarding the client's health history, preferences, and any other confidential details discussed before, during, or after the session, further ensuring the client's privacy and comfort.

Cancellation Policies

100% Full Payment is required for the following conditions:

No Show: If you do not show up for an appointment, you will be charged the full amount for the appointment.

Last-Minute Cancellation/Reschedule: Failure to cancel or reschedule your appointment at least 24 hours in advance, you will be charged the full amount for the appointment.

Late Arrival: If you are late to your session you are welcome to receive whatever time is left for your appointment.

Informed Consent

By typing my first name, last name, and providing my e-signature below, I confirm that I have read, fully understand, and agree to all the questions and statements provided in this Massage Therapy Consultation Form in its entirety.

Type Full Name:*

First NameLast Name

Client or Parent / Guardian Signature*

Today's Date*

MonthDayYear

Please take a photo of yourself.

Please list areas of the body you would like focused therapy on:

Please list areas of the body you want avoided:

Please list any Car Accidents

Level of Exercise:

High - Hard, Breaking a sweat after 3-5 minutes. Breathing is deep and rapid. High Intensity.Moderate - Somewhat Hard, Breaking a sweat after 10 minutes, breathing becomes deeper and more frequent.Light - Easy, Does not induce sweating no change in breathing.

Special Consent for Massage of the Breast/Chest Region:

Your therapist shall drape the breasts of all female clients and not engage in breast massage of female clients unless you the client gives signed consent before each session involving breast massage.

In order to achieve individual treatment goals, your therapist may deem it appropriate to work on muscles or connective tissue within breast/chest region. Treatment of certain conditions of the breast/chest, rib cage, chest muscles and back issues will be most effective when it is preceded by the relaxation of surrounding muscles. This includes the pectoralis major, pectoralis minor, intercostal muscles, and scar tissue. Please let your therapist know immediately if at any point you wish to stop the massage of the breast/chest area or if treatment feels uncomfortable in any way.

Consent for Massage of the Breast and Chest Region