SDP Intake & Service Agreement – I-thriv: Wellness, Anywhere LLC

Client Full Name*

First NameLast Name

Start Date*

Date

Client Email Address*

example@example.com

Client Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Client Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Primary Contact Full Name

First NameLast Name

Relationship to Client

Primary Contact Email Address

example@example.com

Primary Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

FMS Agency Name

FMS Contact Person

FMS Contact Email

example@example.com

FMS Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

Requested Service(s)*

Session Frequency & Rate*

Weekly @ $140 for 1 hour sessionBi-Weekly @ $145 for 1 hour sessionMonthly $ $150 for 1 hour sessionThree Times Per Week (3x per week) – $135 per session for 1 hour sessionOther

Preferred Day/Time for Sessions*

Provider Preference*

No preferenceMale providerFemale provider

Session Focus Areas (Select all that apply)

FullbodyNeck, Back and ShoulderLegs and Feet OnlyOther

Please describe any relevant health conditions, allergies, or sensitivities.*

Does the client have any known allergies?*

YesNo

If yes, please list the allergies.

Does the client have temperature sensitivities?*

YesNo

If yes, please describe.

To ensure smooth scheduling and timely payment processing through your FMS:

A valid FMS card must be kept on file for all bookings. This will only be charged the amount of the payment that was only approved.

Invoices are issued once per month for all completed services.
Once your invoice is sent, we kindly ask that it is reviewed and approved within 24 hours by your FMS or Service Coordinator to avoid delays.
If payment is delayed due to lack of approval, future sessions may be paused until the account is up to date.
We work closely with families and FMS providers to keep services consistent and stress-free, and we appreciate your support in helping us maintain timely processing.

Cancellation, Rescheduling & No-Show Policy
Please review and confirm your understanding of the following:

24-hour notice is required for cancellations or rescheduling.
Same-day cancellations or missed appointments may be subject to the full session fee.
If a provider is unavailable due to illness or emergency, we will:Offer a replacement provider, or
Reschedule your session at the next available time.

Acknowledgment
By signing below, you acknowledge that you have read and agree to the policies outlined above for services with i-thriv: Wellness, Anywhere LLC.

I have read, understand, and agree to the Cancellation, Rescheduling & No-Show Policy.*

I agree

Additional Service Policies & Agreements

Signature*

Date*

Date

SDP Intake & Service Agreement – I-thriv: Wellness, Anywhere LLC

Client Information

Primary Contact Information

FMS Information

Service Details : Massage Code 374

Health, Allergies & Sensitivities

Payment & Billing Policy (SDP Services)

Agreement Acknowledgment