Client Intake Form

Only fill this out if you have already booked an appointment. This form must be filled out prior to your appointment.

For minors under 17 years, a parent or legal guardian must come to the appointment and sign a minor consent form in order for their child to receive treatment.

First Name

Middle Initial

Last Name

Street Address

City

Region/State/Province

Postal / Zip code

Birth Date

Phone

Occupation

Emergency Contact Name

Emergency Contact Phone

How did you hear about us?

Reason for appointment

Have you ever experienced professional massage or energy work?

Yes

How often do you receive massage or energy work?

If yes, how recently?

What areas do you feel are giving you trouble?

Session type desired (check all that apply)

Therapeutic

Relaxation

Chakra Balancing

Reiki

Guided Meditation

Prenatal

Hot Stone

Himalayan Salt Stones

Cupping

Thai Foot Massage

Crystal Healing

Sound Healing

If you checked off any conditions above, please explain:

Do you frequently suffer from stress?

Yes

Have you ever had surgery?

Yes

If yes, please explain:

Have you suffered any accidents or injuries in the past two years?

Yes

If yes, please explain:

Are you pregnant?

Yes

N/A

If yes, how many weeks?

Are you taking any medications?

Yes

If yes, please list:

Do you have any contagious illnesses?

Yes

If you have a contagious illness at the time of your appointment, please reschedule.

Are you sensitive to touch or pressure anywhere?

Yes

If yes, where?

Is there anywhere you do not want touched that would normally be touched during a professional massage?

Yes

Example: You don't want feet or scalp worked on.

If yes, where?

Do you have any implants, plates, screws, etc.?

Yes

If yes, where?

Please read the following statements:

I (the client) am aware that full draping will be used during the session, unless clothing is worn.
I understand my underwear stays on during the session.
I understand that it is not within scope of the session for the therapist to engage in breast massage.
I understand that any illicit or sexually suggestive advances or remarks made by me will result in immediate termination of the session, and I will be liable for full payment of the scheduled appointment.
I understand that my feedback is important. Therefore, if at any time I should become uncomfortable during the session, I am to bring it to the therapist's attention and request that the session end.
I understand that if I end the session early, I am liable for full payment of the scheduled appointment.
I understand that no photography or recording or streaming of any kind is allowed in the treatment room without the therapist's written consent.
The treatments given at Spirit of Lotus Healing Arts are for the sole purpose of stress reduction, relief from muscle tension, spasm, or pain. The therapist does not diagnose or prescribe for medical illness, disease, or any other physical or mental disorder. Nothing said during the session should be construed as such.
The therapist does not do spinal manipulations.
Massage therapy, energy work, crystal healing, and other holistic alternative therapies are not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for any ailment that the client may have.
I understand it is my responsibility to explain and discuss all medical conditions and medications with the therapist.
I have read and understand this form in its entirety. If at any time there are changes in the information given, or in my condition, I will notify my therapist and update this form before receiving additional treatments.

I have read and agree to all of the statements above.

Please read the guidelines:

Time

Client is required to give a 24-hour cancellation notice, otherwise the client must pay the full cost of the session. Clients who have been moved to 48-hour or 72-hour notice programs must abide by those guidelines.
A session can be lengthened based on the therapist's schedule.
If a client shows up late for an appointment, the client will be billed for a full session and treated for the remaining time of the session. If the client is 15 minutes late or more, the appointment must be rescheduled and payment made in full.
If an emergency occurs for either the client or the therapist, the session may be rescheduled based on a mutual agreement.

Confidentiality

The therapist does not share information about the session with others, unless required by law.
If the client would like the therapist to send a note to a physician, the client must make the request in writing.

Treatment

The client determines which pieces of clothing to be removed.
The therapist discusses what is most helpful for the specific treatment; however, the client makes the final decision.
The client determines which areas not to treat (i.e., no foot strokes due to being ticklish); likewise the therapist determines which areas not to treat (i.e., genitals, breasts).
The client will remain covered at all times and only the area being worked on will be uncovered.
The client needs to communicate the pain level to the therapist.
Treatment is provided in a specific designated space that is used solely for massage and energy healing where the client’s privacy is assured.
If the client would like another person (i.e., spouse, parent) to observe the session, that may occur provided the person adheres to the established boundaries, and the therapist agrees.
The massage therapist reserves the right to refuse treatment for any reason.
The client must practice proper hygiene prior to the appointment.
No sexual behavior/intonation is tolerated. Any sexual behavior, remarks, advances, etc., will result in the session being ended immediately, the client will be required to pay the full cost, and will be banned. The therapist may file a police report and take other legal action.

Payment

Payment is due at the time service is rendered.
Gift Certificates and packages are available and are paid in advance of service; certificate or package to be used within a twelve month time frame. No refunds on gift certificates or packages.

Agreement

I (the client) agree to adhere to the specified boundaries. If for some reason I cannot adhere to the boundaries, the therapist will discuss a course of action that may result in a right to refuse treatment.

I have read and agree to all of the guidelines above.

Sign your name here acknowledging you have filled out this form to the best of your ability and knowledge, and agree to the policies and guidelines outlined above.