Senior Care Approval Consideration Form

Senior Care Approval Consideration Form

Decompressed by KJ
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Please review the membership structure. complete the corresponding questionaire, then scroll to the bottom and click submit.

We will review your submitted application and follow up with you directly.
Senior Care Membership includes:
- In-studio sessions only.
- Commitment based pricing (at 20% off standard rates) for ages 60+
- 1 x 60 minute swedish massage per month (or 2 x 30 minute). You may upgrade to longer sessions or other massage modalities. Any difference in cost will be collected in person, immediately after the session is complete.
- Extended check-ins and unrushed transitions.
- Locked-in rate (for first 12-months) in the event of a price increase.
- 12 month minimum committment.
- Auto pay required.
- Availability is limited to ensure safety, consistency, and quality of care.
The following questions apply to 'Senior Care' membership only. Completing this form does not guarantee placement.
Who will be receiving care?

MyselfA parent or loved oneA client I manage care forOther
Is the client able to communicate discomfort or pain clearly?

YesNoSometimes
Will a caregiver, family member, or staff be present during sessions?

YesNoNearby but not in the room
Senior care memberships are designed for consistent, recurring support. Are you comfortable with a set care rhythm (monthly or bi-weekly) held on a recurring schedule?

YesNoPossibly. I'd like additional information.
Which statement best reflects your expectations of care?

Gentle, comfort focused careSupport for circulation, relaxation and mobility.Supportive, therapeutic touch
Does the client have the ability to give informed consent at the time of each session?

YesNoOther
Are you comfortable with the following? (Check all that apply)

Auto-billing for membership careNo rollovers for missed sessions24-hour notice required for rescheduling
Completing this form does not guarantee placement. If alignment feels mutual, next steps will be shared privately. Please click 'submit' for consideration. We will follow up with you directly with a decision.
Should be Empty: