If yes, how do you think it has affected your health. Circle the area in roughly the size and shape of your paintenderness, numbnesstingling, or jointmuscle stiffness. I understand that massage therapy is given for the purposes of stress reduction, increased circulation and relief from muscular paintension. The therapist will massage the necessary body parts to facilitate the massage excluding any contraindicated areas. If you dont have a printer, just come in a few minutes early before your first session. Please know that your massage therapist is not a physician and cannot diagnose, prescribe or treat any physical or mental.
Circle any specific areas you would like the massage therapist to concentrate on during the session. Signature date confidential client intake form stephen williams. Medical information are you taking any medications. Mental health intake form all information on this form is strictly confidential patient first name. Because massage should not be performed under certain medical conditions, i affirm that i have stated all my known medical conditions and answered all questions on the client intake form honestly. Ive also benefitted from the free intake forms and things. This consent form normally pairs together with the massage intake form.
Although there are varieties of massage intake forms that highly depend on the expertise and specializations of the massage therapy center, there are certain contents of a massage intake form that should be kept and be included regardless of its variety. I understand that the massagebodywork i receive is provided for the basic. I affirm that i have stated all my known medical conditions and have answered all the questions honestly. Ive also benefitted from the free intake forms and things like that which you put out there. Zen shiatsu therapy intake form mind body and flow. I understand that the massage bodywork i receive is provided for the basic purpose of relaxation and relief of muscular tension. This remarkable massage therapy consent form contains form fields about the client, emergency contact details, current health data, consent waiver, and a digital signature.
Client intake questionnaire please fill in the information below and bring it with you to your first session. Cupping therapy client release form health enhancement therapies 205 county road 119, st. Do you have any concerns or questions regarding your massage today. By signing this form, you certify that you are the parent or legal guardian of the child receiving the massage therapy services. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that i should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which i am aware. Please arrive at least 15 minutes early so you have time to complete the form. I understand that massage therapy is a therapeutic health aide and is nonsexual. Also, client intake form massage is used by chiropractors. Massage therapy client intake form template jotform.
Valerie lindsey, lmt the lindsey group massage therapists. I understand that the massage reflexology work that i receive is provided for the basic purpose of relaxation. Screen out coronavirus with your massage therapy intake form. Client intake form therapeutic massage personal information. Name of person completing form if other than patient. A massage therapy intake form is a powerful means of building trust in the therapeutic relationship. Protect yourself, your clients and your massage therapy practice by utilizing proper documentation techniques. Generally, therapists require patients to fill out the massage intake form.
As massage is a therapy, the therapist providing the massage requires clients to complete a massage intake form. Because massage may be contraindicated for specific medical conditions, i hereby release the massage therapist from any liability if i. Do you experience stress in your work, family, or other aspect of your life. A sample massage therapy intake form that you can actually use october 19, 2015 by allissa haines 2 comments raise your hand if you were using your massage schools sample intake form for the first several years of your massage. See more ideas about massage intake forms, massage, massage therapy. Use amtas client intake forms to fully understand your client before you begin your first massage session. I have completed this form to the best of my ability and knowledge.
Client intake form massage therapy peak performance. Name phone day phone eve address citystatezip email date of birth occupation emergency contact phone the following information will be used to help plan safe and effective massage. Therapeutic massage and manual lymphatic drainage intake. Download and print the massage therapy reiki intake form below pdf to fill out prior to our first session dont forget to bring it with you.
Car collision workers compensation private health massage information have you ever received professional massage bodywork before. An informed consent and waiver form should also be enclosed with the therapy intake form. You can sign up for massage therapy with massage intake form template and you can create a hipaa compliant. I understand that if the massage therapist starts a session late, she will make it. Massage intake form confidential information welcome. I have read and understand this intake form and have completed it to the best of my knowledge and consent to this massage therapy session. Please answer the questions to the best of your knowledge. If i experience any discomfort during this session, i will immediately inform the massage therapist so that the pressure may be adjusted to my level of comfort.
I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist. Intake forms help destress the appointment making process. Underline past conditions check here if explanation below. Massage therapy intake contains different questions about personal information, contact information, history of pathology and the clients symptoms. I understand that the american massage therapy association has provided this form as a reference and is not held r. Oncology massage intake form must accompany a complete. Because massage bodywork should not be performed under certain medical conditions, i affirm that i have stated all my known.
Clients hate wasting time filling out paperwork when theyd rather be on your table, and you have to remember important intake. Client intake form therapeutic massage replenishing me p i. This form was created as a resource by the american massage therapy association and they are not held liable for any services provided. Because massage should not be performed under certain medical conditions, i affirm that i have stated all my known medical conditions, and answered all questions honestly. I am aware of the benefi ts and risks of massage and give my consent for massage. Intake forms serve an important purpose, but are often disliked by both clients and massage therapists alike. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications and that spinal manipulations are not part of massage therapy. By filling out this comprehensive intake form, you are helping us to provide you with more effective care. Massage therapy client intake please mark the areas to identify your symptoms today. I also understand that massage therapy may produce some side effects such as muscle soreness, mild bruising, increased awareness of areas of pain and light headedness, among other possible temporary outcomes. Elizabeth bosse, licensed massage therapist and energy worker. Professional membership and insurance for every therapist. Because massage may be contraindicated for specific medical conditions, i hereby release the massage therapist from any liability if i should intentionally or unintentionally omit information regarding any medical condition that i may have.
Keep track of your massage clients condition and progress with sample soap notes. Intake form template best of massage therapy client intake form printable pdf. Utilize an intake form to fully understand your client before you begin your first massage session, and keep track of your clients condition and progress with soap notes. Simply learning to utilize an intake form can be the positive change you are looking for to help you become the professional massage therapist. Michael, mn 55376 6127166199 i understand that all treatments at this facility are therapeutic in nature. I understand that massage therapy is a therapeutic health aid for the purpose of stress reduction and relief from muscular tension and is nonsexual. Because massage should not be performed under certain medical. Please read and initial that you understand the following policies. Please use one of the drawings on the following pages to indicate areas of discomfort or unusual sensations that you experience. Sprains or strains have you had a professional massage before.
Although there are varieties of massage intake forms that highly depend on the expertise and specializations of the massage therapy center, there are certain contents of a massage intake form. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Client consent and intake form for bodywork and massage treatments. If yes, please complete the billing information form. Utilize an intake form to fully understand your client before you begin your first massage. Client waiver form please take a moment to read the following statements. I just want to say, ive benefitted from your open, honest and nononsense approach to running a massage practice. I understand that essential oils and aromatherapy is a complementary holistic therapy and not intended to treat, diagnose.
I will inform the therapist of all changes in my medical profile. I have not experienced any of the complications listed on the attached sheet. I have informed the massage therapist of all my known physical conditions, medical conditions and medications, and i will keep the massage therapist updated on any changes. Since the therapy intake form will gather the personal information of the client, it is significant that the therapist has acquired the clients legal consent to use all the statements and details that the client disclosed in the form. I understand that the treatments are not substitutes for medical examinations, diagnosis, or any other treatments by a qualified medical specialist. The following information will be used to help plan a safe and e. Blood clots, infections, congestive heart failure, contagious diseases, pitted. Therapeutic massage and bodywork karen bernhardt 6095538833 client intake form evening dob phone personal information name address occupation email emergency contact how did you hear about us. Zen shiatsu therapy intake form all information is kept strictly confidential informed consent to shiatsu therapy it is my choice to receive shiatsu therapy. I agree to communicate to the therapist any physical discomfort or draping issues during the session. Protect yourself, your clients and your massage therapy practice by using proper documentation techniques. Certain medical conditions and symptoms may be contraindicated for massage therapy, thereby requiring a referral from a primary care physician before receiving treatment. I understand the therapist at krave therapeutic massage.
If i experience any pain or discomfort during this session, i will immediately inform the due to some body work being contraindicated for some conditions, i affirm that i have stated all of my initial session client intake form date of. Filling out the form at your leisure will also promote more accurate information. Also known as client intake form, a massage intake form is a way by which therapists record patient contact information, specify policies, and get an idea of the patients issues, medications, and contraindications. A referral from your primary care provider may be required prior to service being provided. The massage therapist will not perform breast massage on female clients without the written consent of the client elements does not perform breast massage. You acknowledge that you are aware of the health risks inherent in any form. Name phone day phone eve address citystatezip email date of birth occupation emergency contact phone the following information will be used to help plan safe and effective massage sessions. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental conditions, nor. Generally, therapists require patients to fill out the massage intake form before their appointment.
I understand that essential oils and aromatherapy is a complementary holistic therapy and not intended to treat. Bellman, lmt, bs healing arts of ohio, 185 wapakfryburg rd, wapakoneta, oh 45895. An informed consent and waiver form should also be enclosed with the therapy intake form to assure that the. The health data prequestionnaire is required to determine how the treatment will undergo. The detailed forms provided below can be downloaded and printed so they may be completed prior to your appointment. I understand that massage therapy may provide benefits for certain conditions, but results are not guaranteed.
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