251215_ther_massage_client_intake_form

Client Intake Form - Therapeutic Massage
Client's Full Name*
Phone (Day)*
Phone (Eve)
Street Address*
CityStateZip*
email address*
example@example.com
Date of Birth*

MonthDayYear
Date
Occupation*
Name of Emergency Contact
Emergency Contact's Phone
The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.
Date of Initial Visit

MonthDayYear
Date
1. Have you had a professional massage before?*

YESNO
If yes how often do you receive massage therapy
What modalities of professional massage therapy/bodywork have you experienced in the past (check all that apply)?

Deep TissueSports/Facilitated StretchingGentle/Relaxation/SpaSwedish™Thai Yoga BodyworkBarefoot/AshiatsuShiatsu/Acupressure/Tui NaHot Stone/Himalayan Warm StoneFacial Lift/Buccal MassageCraniosacral Therapy/Somatoemotional Release (Upledger)Myofascial Release (Barnes MFR)Manual Lymphatic Drainage (Klose/Vodder/Chikly)Medical/Orthopedic MassageKinesiology tapingDry needlingNeural ManipulationVisceral ManipulationPrenatal/Postnatal MassageFunctional Movement RetrainingReikiZero BalancingRehabilitative/Post-Surgical MassageTrigger Point TherapyInstrument Assisted Soft Tissue Manipulation (IASTM)/Graston™/Gua ShaMassage CuppingOther
If you know, what level of pressure do you prefer?

1

2

3

4

5

1 is Very Light Pressure, 5 is Firm/Deep Pressure
From the professional massage experience you have had, if anything, what techniques did you NOT LIKE RECEIVING from any previous therapist?
2. Do you currently have any difficulty lying on your front, back, or side?*

YESNO
If yes please explain
3. Do you have any allergies to oils, lotions, or ointments?*

YESNO
If yes please explain
4. Do you have sensitive skin?*

YESNO
5. Do you wear*

contact lenses/eyeglassesdentureshearing aidsI do not wear any corrective devices as listed aboveOther
6. Do you sit for long hours at a workstation, computer, or driving?*

YESNO
If yes please describe
7. Do you perform any repetitive movements in your work, sports, or hobby?*

YESNO
If yes please describe
8. Do you experience stress in your work, school, family, or other aspect of your life?*

YESNO
If yes, how do you think it has affected your health? (check all that apply)

muscle tensionanxietyinsomniairritabilityOther
9. Is there a particular area of the body where you are experiencing tension, stiffness, pain, or other discomfort?*

YESNO
If yes please identify
10. Do you have any particular goals in mind for this massage session?*

YESNO
If yes please explain
What specific areas would you like the massage therapist to concentrate on during the session?*
In order to plan a massage session that is safe and effective, the provider needs some general information about your medical history.
11. Are you currently under medical supervision?*

YESNO
If yes please explain
12. Do you see a chiropractor or osteopath?*

YESNO
If yes how often:
13. Are you currently taking any medication or supplements?*

YESNO
If yes please list:
14. Please check the condition(s) listed below that applies to you now and in the past five (5) years:*

NO MEDICAL CONDITIONS CURRENTLY or IN THE PAST FIVE (5) YEARSallergies/sensitivityaneurysmartificial jointatherosclerosisback/neck problemsblood clots/deep vein thrombosishigh or low blood pressurecancercarpal tunnel syndromecirculatory disordercontagious skin conditiondecreased sensationdiabeteseasy bruisingepilepsycurrent feverfibromyalgiaheadaches/migrainesheart conditionherniaopen sores or woundsosteoporosisphlebitisrecent accident or injuryrecent fracturerecent surgerysprains/strainsstrokeswollen glandstennis elbowvaricose veinsjoint disorder/rheumatoid arthritis/osteoarthritis/tendonitisTMJ DysfunctionPregnancyOther
If currently pregnant, how far along in weeks are you now?
Please explain any condition(s) that you have marked above
15. Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
If client is a MINOR (under the age of 18 years old), Parent/Guardian must complete the PARENT/GUARDIAN section below. Otherwise, skip THIS SECTION and proceed to the Client/Parent/Guardian Signature section.
All clients under the age of 18 must be accompanied by a parent or legal guardian to their appointments. Parents/guardians are welcome to remain in the waiting area during the session. If they voluntarily choose not to stay on the premises for the duration of the session, a waiver must be completed and signed acknowledging this arrangement. Additionally, informed written consent for the session must be provided by parent or legal guardian for any client under the age of 18.

The client/parent/guardian also understands that, as of November 7, 2025, written informed consent must be provided by the client (or parent/guardian if the client is age 17 or under) immediately prior to each session per State Massage Therapy Regulation and the form will be completed before the commencement of the visit.
PARENT/GUARDIAN WAIVER FOR MINORS:

By signing this "Informed Consent and Waiver", I consent to receiving therapy with Jessica N. Ferrer, LMT and hereby agree to all policies of her clinical practice, and waive and release Jessica N. Ferrer, LMT and any of her staff, massage therapists, and body work practitioners from any and all past, present, and future liability, loss, cost, claim, or damage whatsoever which may be imposed upon the Company relating to massage therapy and body work; including but not limited to reflexology, acupressure, polarity therapy, energy therapy, Reiki, nutritional therapies, all forms of kinesiology, aromatherapy, craniosacral therapy, myofascial release therapy, trigger point therapy, stretching therapy, strength and condition training, among others. I further undertake to indemnify and hold Jessica N. Ferrer, LMT and her massage therapy clinical practice harmless from any incident(s) arising from the use of the services provided.

If the client is less than 18 years old, the Client's parent and natural guardian hereby represents that he/she is, in fact, acting in that capacity, has consented to his/her child or ward's availing of the services of Jessica N. Ferrer, LMT, and has agreed individually and on behalf of the child or ward, to the terms of this "Informed Consent and Waiver". The undersigned parent or guardian further agrees to save and hold harmless and indemnify Jessica N. Ferrer, LMT from all liability, loss, cost, claim, or damage whatsoever which may be imposed upon Jessica N. Ferrer, LMT relating to massage therapy and body work; including but not limited to reflexology, acupressure, polarity therapy, energy therapy, Reiki, nutritional therapies, all forms of kinesiology, aromatherapy, craniosacral therapy, myofascial release therapy, trigger point therapy, stretching therapy, strength and condition training, among others, on behalf of the Client and all of the Client's parents or legal guardians.
Printed Parent/Guardian's Full Name
Parent/Guardian Email Address
example@example.com
Parent/Guardian's Telephone Number
I agree to and acknowledge the foregoing on this day of
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Signature of Client or Parent/Guardian*

Clear
Should be Empty: