Minor Client Intake Form

Minor Intake Form

All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent.
Minors are welcome to receive massage therapy with A Classic Touch of Therapy, provided that certain conditions are met. A parent or legal guardian must complete the Minor Intake Form and provide consent for the massage session.

Guidelines:
- Minors (under 18, unless emancipated) require written consent from a parent or legal guardian to receive massage therapy.
- The massage therapist will work with the consenting adult and child to set goals for the session(s).
- For clients aged 15 and under, a parent or guardian must be present in the room where the massage is taking place at all times.
- For clients aged 16-17, if both the client and the parent/guardian are comfortable with the client being in the treatment room alone, please initial below. Otherwise, a parent or guardian should be present during each session. Once a trusting therapeutic relationship has been established and all parties are comfortable, the parent/legal guardian may choose not to be present in the room.
- Appropriate draping will be used throughout the massage, ensuring that only the areas being massaged are uncovered.
Intial or Sign & Date Below

Please only initial if you consent to your 16 or 17 year old minor being alone in the room dedicated for the massage session.
Parent/Guardian Initials: intial here .
Minor's Initials: initial here .
I, blanks am the parent/legal guardian ofblank . I have read the above information and give permission for my child, to receive massage therapy from Tisha McDuffie, A Classic Touch of Therapy or any other Massage Therapist associated with this company.
Signature Date
PERSONAL INFORMATION
Date*

MonthDayYear
Date
Child's Full Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Parent's Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
This is my:*
E-mail*
example@example.com
Emergency Contact*
Phone Number*

Area CodePhone Number
How did you hear about us?
MINOR'S MEDICAL INFORMATION
Is your child taking any medication?*

Yes (if yes, please list below).No
Medications
Does your child complain of any chronic pain?*

YesNo
If you answered Yes above, please list the chronic pain and explain what makes it better/worse?
Has your child had any orthopedic injuries?*

YesNo
Please List Orthopedic Injuries.
Does your child have any conditions that we should be aware of (i.e. ADHD, Autism, etc.)? Please list below.
MASSAGE INFORMATION
Has your child had a professional massage before?*

YesNo
What type of massage are you seeking?

RelaxationTherapeutic/Deep TissueSpecific Muscle/ Area (List Below)
What specific muscle(s) or area(s) would you like massaged?
What type of pressure does your child prefer?*

LightMediumNot Sure, 1st experience
Do you have any allergies or sensitivities to oils, lotions or scents etc.?*

YesNo
Please list any allergies/sensitivities:
Are there any areas (feet, face, abdomen, glutes, etc.) that you do NOT want me to massage?
Massage Policies:

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

       • Please turn off your cell phone for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please reschedule your session if you will be more than 15 minutes late

       • 24 hour cancellation notice is required to avoid being charged for your session

       • You will be draped and at no time will genitalia or breast tissue be exposed

       • You may have a consultation with your therapist before your appointment to discuss your session

       • You may disrobe to your comfort level, after your therapist has left the room

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

       • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Client Agreement:

I understand that massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage 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 therapeutic massage as a form of therapy.

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 massage therapist so they can adjust.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless A Classic Touch of Therapy, LLC, and my massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.
Have any questions? Please type it here.
Signature*

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

Intial or Sign & Date Below

PERSONAL INFORMATION

MINOR'S MEDICAL INFORMATION

MASSAGE INFORMATION