Intake & Consent Form

Name

Pronouns

Phone

Address

Street Address Line 2

Email

Date of Birth

Emergency Contact

Emergency Contact Phone

What are your goals or thoughts for this session?

Have you ever had professional therapeutic massage or bodywork before?

Do you have any health histories you would like to share with me? (not required)

Are there any medications I need to know about?

Describe any allergies to scents, lotions, or oils

Policies & Procedures

Appointment Information/Rescheduling Policy Please arrive a few moments before your scheduled time to prepare for service. This allows for a relaxed and unhurried experience. If late arrival is inevitable, please call or text me at 937-545-7839 and let me know. Timely arrival to your appointment respects my time and other clients' time.

I ask that you give at least 24 hours of notice as a courtesy if you are needing to reschedule your appointment. To do so, you may call or text 937-545-7839 or email katethomas.lmt.collectivegood@gmail.com. If an appointment is missed, or cancelled or rescheduled with less than 48 hours of notice, the client will be charged a cancellation fee of 100% of the service charge.

Scope of Practice I am a licensed professional and held to the highest standards of the American Massage Therapy Association. Massage therapy is a profession in which the practitioner applies manual techniques with the intention of positively affecting the health and well-being of the client. Massage therapists do not diagnose or prescribe for medical conditions nor are they allowed to provide treatment for a specific condition without a doctor's supervision.

General Expectations Massage sessions are by appointment only. Privacy and confidentiality will be maintained at all times. The Informed Consent Agreement must be read and signed, and the client will be provided with this copy of the massage policies prior to the first session. Not every muscular issue you have may be addressed during a given session, but I strive to improve your overall well-being while working with you toward your treatment goals by the time your session is complete. Your practitioner reserves the right to refrain from performing massage on clients who appear to be under the influence of alcohol or drugs. It is the responsibility of the client to keep the massage therapist informed of any medical treatment currently being taken. The client must also keep the massage therapist informed of any changes in health conditions. Please, refrain from smoking immediately prior to the session. I reserve the right to refuse treatment to any client who has an overabundance of nicotine odor on their skin.

Draping Policy You may undress to your comfort level. Clients are covered and draped with sheets and blankets, only uncovering the body area to be worked on. If you feel unsafe with this draping style, it will be adjusted to your comfort level. Private areas are never exposed or massaged.

Respect for Client Boundaries I am happy to adjust pressure, work longer on an area, or move on if you request. The client may choose to: leave on as much clothing as needed for comfort, refuse any massage methods, stop massage at any time and is free to leave. The client will always be modestly draped. Only the area being massaged will be undraped. The clients will be kept informed of the area to be massaged.

Professional Boundaries The practitioner will not engage with clients in intimate social or personal relationships. Personal and professional boundaries are respected at all times. The practitioner only performs services for which she is qualified professionally, physically, and emotionally. Referrals to the appropriate specialists are made when working with the client is not within the scope of practice of the massage therapist or not in the client's best interest. All client information is held confidential. I do not massage anyone under the age of 18 unless the parent or guardian is in the room and signs their release form. All clients are treated with respect regardless of their age, gender, race, abilities, color, body type, culture, national origin, sexual orientation, religion, socioeconomic status, educational status, political affiliation, state of health, or personal habits.

Zero Tolerance There is zero tolerance for sexual harassment in my massage practice. Requests for sexual activity will not be tolerated, will be viewed as solicitation, and reported to the proper authorities under the guidelines of the massage therapy policies and procedures. The client will be charged the full session amount and will not be rescheduled if this occurs.

Informed Consent (sign below) By signing this form, you acknowledge you understand Collective Good Integrative Health's policies and procedures, listed above. You agree to adhere to late, cancel, and no-show policies. You further agree that you have provided the therapist with all current, relevant medical information, and that you release the therapist from any liability for harm or injury resulting from a failure to provide such information. You assume responsibility for providing your therapist of any relevant changes in health and/or medical treatment over the course of the therapeutic relationship. This is a professional, therapeutic massage and any sexual or otherwise inappropriate behavior will result in the session coming to a close with the full price for the session due immediately. I understand that the massage therapist is providing massage therapy services within their scope of practice as defined by the State Medical Board of Ohio. I have read the above noted content and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me. I understand that at any time I may withdraw my consent and treatment will be stopped.

Client Signature

Date