New Client Intake - Formstack

First Name
Last Name
Date of Birth
Address Line 1
City
State
ZIP Code
Email
Phone
Occupation
Please list your occupation so your therapist can better understand your needs.
Name of Physician and Phone Number
For collaborative and customized treatment plans, and/or emergency purposes.
What type of physical activity or extracurricular activities do you do and how often?
Any repetitive motion can heavily impact our body and its needs.
Emergency Contact Name & Phone Number
Where did you hear about us?

Google SearchYelpSocial MediaOther
Were you referred by someone? If so, please list below.
Cancellation Policy:

I understand that the Cancellation Policy can be found online at deeptissueboise.com or on my booking email confirmation, as well as the booking site itself. I understand I will be charged up to the full amount of my service cost if I do not cancel in the timeframe specified or if I miss my appointment without any notice. I understand I can cancel through the booking site, my confirmation email, or by leaving a voicemail or text through the business listing. I understand that any notice is better than no notice when cancelling.
Signature Consenting That I Understand And Agree To The Cancellation Policy.*

Clear
Jackie's Individual Policies & Practices
1. Arrive 5 Minutes Early. This ensures that your session starts at its scheduled time. Jackie deducts 5 minutes from every session to allow for the time it takes clients to get on/off the massage table and to checkout and reschedule appointments. The hands-on time you receive will be impacted by on time and late arrivals. Even arriving "on time" will cut into your time on the table. Arriving 5 minutes early and starting at your scheduled time is best practice. ***Arriving more than 5 minutes early will not lead to more time spent on the table. Starting earlier than scheduled means ending earlier than scheduled.

*Eric works at a leisurely pace and has a large buffer gap between appointments to accommodate clients arriving a few minutes late or working longer than scheduled. Jackie works back to back appointments with a smaller buffer gap in order to see more clients in her day.

2. As a result of increased skin sensitivities due to frequent hand washing over her 10+ years in practice, Jackie wears nitrile gloves in session.
Signature Confirming I Understand Jackie's Individual Policies and Practices:*

Clear
Health History
My general wellness is:

GoodFairPoor
Please check if you have any of the following:

High blood pressureLow blood pressureOsteoporosisFaintingDizzinessVaricose veinsPhlebitis or blood clotsBruise easilyHeart conditionShortness of breathDiabetesChest painsNone of the above
Do you currently have any skin conditions, rashes or warts? If so, where?
Do you have arthritis? Where?
Neck Condition

Pain with movementStiff neckPopping/grinding noisesWhiplashNone of the above
Have you had any neck injuries? If so, explain where and when.
Head

Sinus/allergiesTMJGrind teethLight bothers eyesLight-headedRinging in earsNone of the above
Do you experience headaches? Where? Frequency? Usual treatment?
Have you had any recent head injuries? If so, what and when?
Shoulders

Pain when raising armPain on rotationBursitisNone of the above
Have you had any shoulder injuries? If so, explain where and when.
Arms and Hands

Numbness/tinglingHands coldLoss of grip strengthShooting painsNone of the above
Have you had any injuries to arms or hands? If so, explain where and when.
Back

Upper back painMiddle back painLower back painDisc problemsPain when liftingPain when sittingPain when workingNone of the above
Have you seen a doctor or chiropractor for any of the above conditions? If so, when? What was the result?
Hips, Legs and Feet

NumbnessShooting painsTicklish feetHip replacementKnee surgerySciaticaNone of the above
Have you had any injuries or surgeries for any of the above checked conditions? If so, when?
Please list any medications you are currently taking.
Are you pregnant or experiencing any abdominal symptoms. If so, please explain.
Please describe any recent illness, broken bones, injuries/surgeries not listed above (including dental surgery), skin allergies, or any other conditions or information you feel we should know.
Narrowing Your Treatment Plan
Please briefly describe your perfect session.
Please describe your perfect pressure. Firm, Medium, Light?
Please describe any disappointment or dissatisfaction regarding ANY previous massage you have received.
Everyone is different and we want to make sure you enjoy a perfect experience that is entirely your own!
The following are massage caveats we want to avoid. Tell your therapist if you are experiencing any of the caveats listed below.

Our goal is to provide an experience completely customized to your needs and pressure/style specifications.
Please check when true during any previous massage.
Not enough pressure used

Accessed only superficial (top) tissue layersDid not access desired muscle tissueNever experienced this problem
Too much pressure used

Depth was uncomfortableDepth was uncomfortable due to sore, sensitive muscles/areasDepth was uncomfortable due to direct, focused pressure (use of fingers, knuckles, thumbs or elbows)Would have preferred broad pressure using long, soft strokes (use of forearms and palms)Never experienced too much pressure
The pace of the massage was distracting

Repetitive strokes, specifically on one area or another, distracted from relaxation of massageFlow of massage lacked connectivity; experience seemed choppyPace of therapist’s movement from one body area to another was too fast to promote relaxationPace of therapist’s movement from one body area to another was too slow to be relaxingNever experienced this problem
Looking to Experience “Good Hurt”

Access varying tissue layers with specific, desired pressure (generally more firm); affects immediate and recognizable reliefI am not looking to experience this depth level
Below are common styles that can emerge in a typical massage session.

Please check for the style/attributes that you would like to experience during this session.
Check any style of depth that describes your desired experience.
Looking for an Experience that “Hits the Spot”

Access varying tissue layers affecting immediate and recognizable relief in a pleasant and relaxing wayI am not looking to experience this depth level
Looking to Experience “Relaxation”

I’m just looking to relaxFirm pressure is uncomfortable to meI prefer broad pressure with soft, stimulating strokesI am seeking some relaxation along with a style listed above.My visit is goal-oriented only; relaxation is not a priority
It is our goal to empower you to understand the basics of your body. Knowing your body will help you communicate with your therapist in order to facilitate the best results.
Please view the following image to determine (to the best of your ability) which muscles or areas are the reason for your visit.

*Zoom in if necessary to determine muscle names
From the above image. List any problem areas that you have, or muscles that need specific work during your visit.
Please list any areas you would like your therapist to avoid.
Please describe your pain or discomfort to the best of your ability.
On a scale of 0 to 10, my pain or discomfort is:
My main priority for today’s session is:
Please check one of the following:

I would like a full body massage with some focus work on my problem areas.Relieving pain or discomfort in my problem areas is my main concern. This visit, a full body massage is not necessary.Relief to my main problem areas is my main concern, if time allows, more areas may be addressed.
INFORMED CONSENT & COVID RELEASE OF LIABILITY
In undertaking a massage with Deep Tissue Boise, I agree to the following:
The purpose of the massage is to provide stress relief, pain control and relaxation. I do not expect, nor will I ask my therapist to diagnose, prescribe for, or treat any of my symptoms. I understand that any relief of physical or emotional symptoms is the product or process that resides in me. The therapist cannot “fix” me.

I understand that I am responsible for my emotions, feelings, body and belongings and that the therapist is responsible only for giving a massage. Control of the session is mine and I can always say, “Stop.” I understand that in order to receive a massage, it is necessary for me to remove my clothes. Anyone receiving a massage will be modestly covered with a sheet at all times as required by law. I understand that massage to the gluteal area or upper/inner thighs is often necessary for achieving requested relief and should in no way be interpreted as a sexual advance. I understand I may request at any time (before or during the massage) that these areas be avoided should massage in these areas make me in any way uncomfortable.

I do not expect, nor will I ask my therapist to discuss or perform a sexual act. I understand that my therapist will not engage in any discussion of a sexual nature and that the massage will be terminated immediately if any verbal or physical sexual suggestions are made. I understand that Indecent Exposure is a misdemeanor offense that will be immediately reported to the police. I understand that my therapist is ethically and legally prohibited from ever engaging in any physical activity or romantic relationship with me or any client of Deep Tissue Boise.

Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly.

In the spirit of understanding, I agree to hold Deep Tissue Boise, Idaho Wellness Group, and my therapist blameless for any problem that might arise as a result of my massage sessions.

INTOXICANTS

It is the policy of Deep Tissue Boise that, for the safety of the therapist and client, massage services will be denied to clients who consume alcohol or drugs prior to their appointment or who appear to be under the influence of alcohol or drug consumption when they arrive for their appointment. I agree to comply with this policy.

INFECTIOUS CONDITIONS

My therapist is informed about infectious illness and skin conditions and routinely practices to protect himself/herself and others from the spread of disease. Any person who is experiencing abnormal or uncontrollable secretion or excretion of bodily fluids such as bleeding, vomiting, diarrhea, should not receive a massage until the condition is resolved.

Any person who has a contagious condition including, but not limited to, strep throat, flu, chicken pox, measles, staph infection, or an infectious skin condition such as impetigo, ringworm, shingles or scabies should not give or receive a massage until the condition is no longer contagious. Other contagious skin conditions that should be made aware to the therapist include, but are not limited to, cold sores and warts; informing your therapist about these conditions will stop the spread of these conditions to other parts of my own body, the therapist, and other clients.

The therapist will use disposable gloves, a finger cot or adhesive bandage if the skin on her hands is not intact due to cuts, burns, abrasions, chapping, or damaged cuticles.

I Have Read and Agree to all of the above Informed Consent:*
Signature*

Clear
Use your mouse or finger to draw your signature above
REDUCING RISK OF ILLNESS & SPREAD OF CONTAGIONS
These are best practices to minimize the risk of spreading airborne and contact pathogens.

1. Please Check Your Temperature Before Arriving. Your appointment should be rescheduled if your temperature is 100.4 or above. Exposing your therapist to fever and other covid-19 symptoms could put your therapist at risk, and therefore any clients that follow. Arriving with symptoms also threatens the safety of the other therapists at Idaho Wellness Group including their clients.

2. Reschedule if you are experiencing even mild symptoms or have experienced symptoms in the two weeks prior to your appointment. Exposing your self-employed therapist can directly impact their physical and financial wellbeing while also putting other clients at risk.

3. Masks are Available Upon Request. Unsure if you experiencing symptoms or if you have been exposed? Masks can help minimize risk of spreading airborne pathogens like covid or the flu. Masks are most effective when both parties in close proximity wear them. Feel free to ask your therapist to wear one if so inclined. *Jackie still continues to wear a mask in session in order to minimize the risk of exposure to herself and to her immune compromised clients.

4. Bring or Wear Slip-On Shoes to wear to and from the massage table. Just like you would at the gym or community shower, keeping your bare skin and socks off of the treatment room floor will help stop the spread of viral or fungal skin infections. The wart virus (HPV) is only killed when in contact with wet bleach or hydrogen peroxide for a solid 6 minutes (this is why pools use chlorine (bleach) water). In order to save our facility floors (and noses) from too frequent a use of harsh chemicals, and to keep your skin safe, please bring or wear your own slip-on shoes OR use the no-cost disposable or reusable slippers we have provided. This is a practice that, unfortunately, is not used enough in massage centers but is highly recommended.

We recommend: stepping out of your shoes and directly into your slip-ons when undressing, walking to the massage table, and then leaving your slip-ons under the table where you can access them following your treatment.

In undertaking a massage with Deep Tissue Boise, I agree to the following:

By signing this form, I acknowledge that I am aware of the risks involved in close contact treatments and give consent to receive massage from Deep Tissue Boise and my therapist.

In the spirit of understanding, I agree to hold Deep Tissue Boise, Idaho Wellness Group, and my therapist blameless for any problem that might arise as a result of my massage sessions.

I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.

I have Read and Agree to all of the above Infectious Conditions Policies and Recommendations, and by signing do so Consent:*
Signature*

Clear
Use your mouse or finger to draw your signature above
Should be Empty:

Jackie's Individual Policies & Practices

Health History

Narrowing Your Treatment Plan

The following are massage caveats we want to avoid. Tell your therapist if you are experiencing any of the caveats listed below.

Please check when true during any previous massage.

Below are common styles that can emerge in a typical massage session.

Check any style of depth that describes your desired experience.

It is our goal to empower you to understand the basics of your body. Knowing your body will help you communicate with your therapist in order to facilitate the best results.

Please view the following image to determine (to the best of your ability) which muscles or areas are the reason for your visit.

INFORMED CONSENT & COVID RELEASE OF LIABILITY

In undertaking a massage with Deep Tissue Boise, I agree to the following:

REDUCING RISK OF ILLNESS & SPREAD OF CONTAGIONS