Therapy Intake Form

Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.
You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Date

MonthDayYear

Full Name

First NameMiddle NameLast Name

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

This is my:

E-mail

Emergency Contact

Phone Number

Format: (000) 000-0000.

Date of reservation

DateHourMinutesAM/PM Option

Occupation

Medications

Allergies

History of Pathology

1. List Areas of Discomfort or Pain

2. Describe Onset of Discomfort or Pain

3. Rate of Pain Today

4. Frequency - please select the most accurate

5. At what time of day is the pain at its worse?

6. Have you ever injured this area before?

7. Have you ever been in an accident (automobile, work, falls, etc.) ?

8. List all related treatments received for this injury.

9. Have you ever received therapeutic massage for a specific problem or injury?

Was the treatment used effective?

10. Is there anything that you do that creates, increases or decreases pain?

11. What are the physical duties required of your occupation?

12. What activities/hobbies do you enjoy?

13. Please list exercise and stress reduction activities (including frequency).

14. In what position do you most often wake up?

Other

15. Are you currently seeing any other healthcare professional?

Please check any symptoms that apply to you and indicate right or left when applicable:

Head

Neck

Shoulders

Arms & Hands

Mid-Back

Low Back

Hip

Legs and Feet

Do you partake of CBD or THC?

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

• Please turn off/ silence your cell phone during treatment for optimal relaxation

• Please schedule with flexibility. No one’s treatment will be rushed or cut short. Having to wait to be seen is not grounds to request a refund. If you have challenges with waiting (which is not the case every session) this may not be the practice best suited for you. We deeply value every guest and are committed to delivering results every experience. Several factors may impact time from the clients condition, weight or size, mobility, etc. You will be given the same concentrated focus during your experience.

•Payments are due at the time of scheduling. If you are using a 3rd party voucher it will be redeemed at the time of scheduling to serve as payment

• 24 hour cancellation notice is required to avoid fees

•Guest canceled sessions will receive a credit for the amount paid. If the practitioner cancels the client will also receive a complimentary add on service.

• You will be draped and at no time will genitalia be exposed

• You will have a consultation with your practitioner to discuss your session and goals

• Should the session require, after your therapist has left the room, you may disrobe to your comfort level

• I understand that my practitioner or I may end the session at any time for any reason

• Inappropriate behavior will not be tolerated (including inappropriate touch,sexual advances, etc.), if either the client or therapist feels uncomfortable or unsafe the session can be terminated without explanation (this does not always mean a refund will be given, it will be assessed on a case by case basis)

•please note that we understand that erection and arousal is a natural reaction to touch, this is not looked at as inappropriate. Feel comfortable to commit with your practitioner with what you need to feel more relaxed.

Client Agreement: I understand that my practitioner does not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization. I acknowledge that holistic 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 services as a form of heating support. I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction. I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my wellness practitioner so they may adjust. I have stated my pertinent medical conditions, and will update the wellness practitioner of any changes in my health status. I understand that my failure to do so may pose a threat to my health and/physical well being and I hold harmless Kwality Life Healing & Wellness and my practitioner from any liability whatsoever arising from failure on my part. By my electronic signature below, I agree to the therapeutic services policy and client agreement above.

I have read all of the above, understand and agree to comply. Please initial below

Insurance (ex: Medicaid, BCBS, Cigna, etc )

Date of completion

Voucher Redemption #

Payment Due/ Gratuity (optional)

USDComplete Payment

Payment Methods

Credit Card

Apple Pay

Cash App Pay

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.