• RCR IN-HOME RECOVERY MASSAGE & BODYWORK

  • NEW CLIENT INTAKE & CONSULTATION

  • Welcome. This form helps me prepare for your session so your appointment can be safe, comfortable, personalized, and effective. Please answer thoroughly and honestly. Your information is used to provide appropriate massage and bodywork services. Fields marked * are required.

  • SECTION 1 | CLIENT INFORMATION

  • Date of birth **
     - -
    2 digit month, 2 digit day, 4 digit year
  • Pronouns (optional)
  • Format: (000) 000-0000.

  • SECTION 2 | WHAT BRINGS YOU IN?

  • What is the primary reason you are seeking massage/bodywork? **
  • Which areas would you most like addressed? **

  • SECTION 3 | PAIN & CURRENT SYMPTOMS

  • Are you currently experiencing pain, numbness, tingling, weakness, restricted movement, or another physical concern? **

  • If you answered No, continue to Section 4. If Yes, complete the questions below.

  • How did it begin? **
  • How would you describe what you feel? **
  • Current pain/symptom level (0 = none; 10 = worst imaginable) **
  • Worst pain/symptom level (0-10) **
  • Do symptoms travel or radiate into another area? **
  • Do symptoms interfere with any of the following? **
  • Have you received a diagnosis for this concern? **
  • Are you currently receiving care for this issue? **

  • SECTION 4 | HEALTH HISTORY

  • Have you ever been diagnosed with or experienced any of the following? **
  • Have you had surgeries or significant medical procedures? **
  • Have you had significant injuries, accidents, fractures, sprains, or falls? **
  • Are you taking medications that may be relevant to massage/bodywork? **
  • Are you taking a blood thinner / anticoagulant? **
  • Do you have allergies or sensitivities? **
  • Any sensitivity to oils, lotions, fragrances, essential oils, adhesives, latex, heat, or topical products? **
  • Are you currently pregnant or postpartum? **
  • Has a healthcare provider placed restrictions on massage, exercise, stretching, positioning, or physical activity? **

  • SECTION 5 | MASSAGE & BODYWORK HISTORY

  • Have you received professional massage/bodywork before? **
  • How frequently do you receive massage/bodywork? (optional)
  • How often do you receive massage/bodywork?
  • Preferred pressure **

  • Pressure and techniques may be adjusted based on your comfort, health history, tissue response, and treatment goals. Deeper pressure is not always clinically appropriate.

  • Conversation preference **

  • SECTION 6 | SESSION PREFERENCES

  • What type of experience are you primarily looking for today? **
  • Are you comfortable with assisted stretching or movement when appropriate? **
  • Are you comfortable with myofascial work, trigger-point / neuromuscular techniques, or therapeutic cupping when appropriate? **
  • Do you have positioning limitations? **

  • SECTION 7 | IN-HOME APPOINTMENT INFORMATION

  • Is the service address in Section 1 where the massage will take place? **
  • Are there stairs or access considerations? **
  • Are there pets in the home? **
  • For safety and to prevent interruptions, please secure pets away from the treatment area before the therapist arrives.
  • Will anyone else be present in the home? **
  • Will children be present? **
  • Do you have an appropriate space for a professional massage table? **
  • Please provide a clean, quiet area with enough room for the table and for the therapist to move safely around all sides. Whenever possible, minimize interruptions during treatment.

  • SECTION 8 | DAY-OF HEALTH SCREENING

  • Are you currently experiencing any of the following? **
  • Certain symptoms or medical changes may require modification, postponement, or medical clearance before massage/bodywork can safely be provided.

  • SECTION 9 | PROFESSIONAL BOUNDARIES & DRAPING

  • RCR In-Home Recovery Massage & Bodywork provides professional therapeutic massage and bodywork services only.

    Appropriate professional boundaries will be maintained at all times. Proper draping will be used, and only the area being worked on will be uncovered. You may request that any technique, body area, or portion of the session be modified or discontinued at any time.

    Sexual comments, requests, exposure, touching of the therapist, or other inappropriate behavior will not be tolerated. Any behavior that compromises professional boundaries or therapist safety may result in immediate termination of the session.

  • SECTION 10 | INFORMED CONSENT

  • I understand that massage therapy and bodywork support relaxation, comfort, mobility, muscular function, and general wellness and are not a substitute for examination, diagnosis, or treatment by a licensed medical provider.

    I understand that the massage therapist does not diagnose illness, disease, or injury; prescribe medication; or provide medical treatment outside the massage therapist's professional scope of practice.

    I have disclosed relevant health conditions, medications, injuries, surgeries, allergies, symptoms, and restrictions to the best of my knowledge. I agree to report health changes that may affect treatment.

    I understand that massage and bodywork may occasionally result in temporary tenderness, soreness, fatigue, or symptom changes. I agree to communicate immediately if I experience pain, discomfort, numbness, dizziness, or another concerning response.

    I may request changes to pressure, positioning, techniques, draping, or areas treated and may stop the session at any time.

    I understand that the therapist may modify, postpone, decline, or discontinue treatment when massage/bodywork may be inappropriate or when medical evaluation or clearance may be advisable.

    I understand that completion of this form does not guarantee that massage/bodywork will be appropriate on the scheduled date. The therapist may modify, postpone, decline, or discontinue a session because of health, safety, professional-boundary, or environmental concerns.

    By signing below, I voluntarily consent to receive professional massage therapy and bodywork services.

  • Date **
     - -
    2 digit month, 2 digit day, 4 digit year

  • SECTION 11 | THERAPIST REVIEW - OFFICE USE

  • Service address and arrival details verified (optional)
  • Follow-up or clarification needed (optional)
  • Items requiring follow-up (optional)
  • Techniques or services discussed (optional)
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  • Should be Empty: