Intake Form

Personal Information

Full Name *

Email *

Date of birth *

Phone *

Street Address

City

State

Country

Postal Code

Occupation

Referred By

The following information will be used to help plan safe and effective massage sessions.

Please answer the questions to the best of your knowledge.

01. Have you had a professional massage before? *

Yes

No

If yes, when did you receive your last massage?

02. Do you have any difficulty lying on your front, back, or side? *

Yes

No

If yes, please explain

03. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? *

Yes

No

If yes, please explain

04. Do you sit for long hours at a workstation, laptop, or driving? *

Yes

No

If yes, how many hours per week?

Please describe

05. Do you perform any repetitive movement in your work or hobby? *

Yes

No

If yes, please describe

06. Do you currently exercise regularly? *

Yes

No

If yes, how many times per week

Please describe type of exercise or sport

Do you currently exercise with a personal trainer?

07. Do you have any current injuries still affecting you? *

Yes

No

If yes, please explain

08. Do you have any old injuries? (i.e. broken/torn/ruptured bones, muscles, tendons or ligaments) *

Yes

No

If yes, please explain

09. Have you had any surgeries? *

Yes

No

If yes, how long ago?

Please describe

10. Are you currently under medical supervision? *

Yes

No

If yes, please explain

List current medications and purpose

11. Do you have any particular goal in mind for this massage session? *

Yes

No

If yes, please explain

12. Is there anything else about your health history that you think would be useful for your massage therapist to know in order to plan a safe and effective massage session for you? *

Please mark any of the following that you now have or have had:

Nervous System

Shingles

Numbness / Tingling

Pinched Nerve

Others

Reproductive

Pregnant

Ovarian / Menstrual Problems

Prostate

Others

Digestive

Irritable Bowel Syndrome

Ulcers

Others

→ 30 Minute Session ($100)

→ 45 Minute Session ($140)

→ Introductory Phone Call

→ In-office Consultation Appointment

→ 30 minute Muscle Therapy/BMC session ($100)

→ 45 minute Muscle Therapy/BMC session ($150)

→ 60 minute Muscle Therapy/BMC session ($200)

→ 90 minute Muscle Therapy/BMC session ($300)

→ 120 minute Muscle Therapy/BMC session ($400)

→ 60 minute Muscle Therapy/BMC session ($570)

→ 6-Week Deep Repatterning Package ($975)

→ 2 hour - Reclaiming Your Energy - In-person ($495)

→ 2 hour - Reclaiming Your Energy - Virtual ($495)

→ 1 hour - 3-Session Private Package (In-person or Virtual) ($495)