Ocean of Life Bodywork - Client Intake Form

Ocean of Life Bodywork - Client Intake Form

Please take some time to complete this form and share anything about your health, body, and experiences that feels important for me to know before our session.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
(Name, Relationship, Phone Number)
Occupation
How did you hear about me?
What is your intention for your session?

Health History
Please describe any areas of tension, discomfort, or pain:
Are their any areas you would like me to avoid during your session?
Please describe any significant accident, injury, or surgery (past and present):
Please list any past or current diagnoses, health conditions, or significant health events that may be relevant to your care (i.e., heart conditions, high blood pressure, cancer history, diabetes, autoimmune conditions, osteoporosis, neurological conditions, chronic pain, digestive conditions, etc.):
Medications/supplements you are currently taking and their purpose:
List any allergies, including oils, lotions, or ointments.

Your Life and Wellness
How would you describe a typical day or week in your life?
What is your average stress level on a scale from 1-10 and why?
What does self-care look like for you? (Consider physical, emotional, and spiritual)
How much water do you drink in an average day?
How is your sleep?
Do you currently or have you previously received therapeutic or healing services? (Massage, bodywork, therapy, acupuncture, energy work, etc.) If yes, please share the type and frequency.

Your Body's Story

These questions help me understand your unique body experience and create a session that feels supportive and personalized. Share only what feels relevant.
Please share anything about your current emotional state, mental wellbeing, or life circumstances that feels important for me to understand.
Please share any experiences related to your menstrual cycle, pregnancy, birth, postpartum, or menopause that feel significant.
Is there anything from your personal history—such as trauma, abuse, or boundary violations—that you feel would be important for me to know in order to better support you during the session?
Is there anything else you would like to share about the story of your body?

Client Agreement
Scope and Limitations of Services

I understand that massage therapy/bodywork is intended to support overall well-being, reduce pain and tension, and provide a therapeutic experience of touch.

I understand that massage therapy/bodywork is not a substitute for medical care, psychotherapy, or medication. The practitioner does not diagnose or treat medical conditions, prescribe medications, or provide psychotherapy or trauma therapy.

I understand that bodywork may bring awareness to physical sensations, emotions, memories, or personal experiences. Depending on the session offered and my individual needs, the practitioner may invite self-awareness, mindful attention, and exploration of internal experiences, within the scope of massage therapy/bodywork.

I agree to inform my practitioner of any relevant changes in my health and to seek appropriate care for conditions outside the scope of massage therapy/bodywork.

Disclosure of Medical Information

I have informed the massage therapist of all known physical conditions, medical conditions, and medications, and I will keep the massage therapist updated on any changes. I understand that the practitioner cannot be held responsible for issues resulting from my failure to disclose relevant information.

Risks and Liability

I understand that the risks associated with massage therapy/bodywork include, but are not limited to: superficial bruising, temporary inflammation of tissues, short-term muscle soreness, and aggravation of previously undiscovered injuries. I therefore release the massage therapist from liability for injuries that may occur during the massage session.

I understand and agree to abide by the therapist’s policies and will not hold the therapist responsible for personal injury or loss of property.
Cancellation Policy
Deposit
To secure your appointment booking, a deposit of $50 is required at the time of scheduling. This deposit will be applied to the cost of your session.

Cancellations/No-Shows
If you cancel less than 24 hours before your appointment or do not show up for your scheduled session, the deposit is non-refundable.

In addition, you will be charged 50% of the session fee, minus the deposit already paid, to cover the time reserved for you.

Extenuating Circumstances
I fully understand that life can be unpredictable, and emergencies may arise. If something unexpected happens, please reach out as soon as possible. I'll do my best to work with you and accommodate your situation in a respectful manner.
By signing below, I acknowledge that I have read and understand the Client Agreement and Cancellation Policy.
Signature
Date

MonthDayYear
Date
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Ocean of Life Bodywork - Client Intake Form

Health History

Your Life and Wellness

Your Body's Story

Client Agreement

Cancellation Policy