Client Intake & Waiver Form

Client Intake & Waiver Form

Share your contact details, health history, preferences, and consent so we can confirm a safe, appropriate Scratch Therapy session.
Client Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health Questionnaire
Do you have eczema?
Do you have psoriasis?
Do you have rosacea?
Do you have any open wounds or cuts?
Do you have any active skin infections?
Do you have any contagious conditions?
Do you have any severe allergies?
Have you had any recent surgery?
Do you have a history of blood clots?
Do you have any suspicious skin lesions?
Do you have neuropathy?
Do you have extreme sensitivity to touch?
Do you have any chronic pain conditions?
Are you pregnant?
List any medications you are currently taking
Describe any other medical conditions or health concerns that may affect your participation
Session Preferences
Areas to Work On
Preferred Tools

Other
Ticklish or Sensitive Areas

Other
Areas to Avoid or Additional Notes
Consent and Acknowledgements
Agreement

By signing below, I acknowledge that I have read and understand the information in this form. I understand that Scratch Therapy is a non-medical, relaxation-focused sensory service and is not massage therapy or a substitute for medical care. I have disclosed any relevant medical conditions, understand that I may stop the session at any time, and agree to communicate any discomfort during my appointment. I acknowledge that I have read and agree to the business policies and informed consent provided.
Liability Waiver
Agreement

I voluntarily choose to participate in Scratch Therapy services. I understand the nature of the service and assume the ordinary risks associated with participation. To the fullest extent permitted by California law, I release Scratch Therapy LA and its owner from liability for injuries or adverse reactions arising from ordinary participation, except where caused by gross negligence or willful misconduct.
Policies
Cancellation Policy

Please notify Scratch Therapy as soon as possible if you need to cancel or reschedule your appointment. Cancellations made within 24 hours of the scheduled session may be subject to a fee, and repeated no-shows may result in limited booking privileges. We appreciate advance notice so we can accommodate other clients and keep the schedule running smoothly.
Late Arrival Policy

If you arrive late, your session may need to be shortened in order to respect the next client’s appointment time. Arrivals more than 15 minutes late may be considered a missed appointment, and the full session fee may still apply. Please plan to arrive a few minutes early so your session can begin on time.
Hygiene Expectations

Clients are asked to arrive clean and free from any strong odors, heavy lotions, oils, or products that may interfere with the service. Please keep all relevant areas accessible and let us know ahead of time about any skin conditions, sensitivities, injuries, or concerns so appropriate precautions can be taken.
Privacy Policy

Scratch Therapy LA respects your privacy and uses the information you provide only to manage your appointment, support your session, and maintain accurate client records. Personal and health information is handled confidentially, shared only when necessary to provide services or comply with legal obligations, and protected using reasonable administrative and technical safeguards.
Agreement
Signature
Client Name

First NameMiddle NameLast Name
Electronic Signature
Date

MonthDayYear
Date
Should be Empty:

Client Intake & Waiver Form

Client Information

Health Questionnaire

Session Preferences

Consent and Acknowledgements

Liability Waiver

Policies

Signature