Atma Prema Wellness || Bodywork Intake
This should take you 5 minutes or less to complete and must be completed prior to first bodywork session. Please answer these questions in full and to the best of your abilities and read my policy statement at the bottom of this form. If something does not apply to you, please answer "N/A".
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メールアドレス *
Personal Information
First and Last Name *
Phone Number *
Address where massage is taking place: *
Preferred method of correspondence: *
必須
Date of Birth *
YYYY
/
MM
/
DD
Occupation: *
Please list regular hobbies/activities (so I can get an idea of movement - even if it includes sitting a lot!):
Emergency Contact (Name, Relationship, Number): *
Home Information
What type of property? *
Where should I park when I arrive? *
Please explain any stair / elevator information: *
Where will I set up my massage table? *
Please list any pets you have:
Will anybody else be home during your session?
Massage Info & Preferences
When was your last massage? *
If you have received professional massage more than once, where did you go?
What areas do you want focused on in your session? *
Describe any sensation (pain or discomfort): *
必須
What is your discomfort level? *
No discomfort
Miserable
Preferred Pressure (check all that apply) *if on mobile, turn phone sideways* *
Please include
Light
Medium
Deep
Very deep
Please avoid
Upper Back and Shoulders
Mid-Lower Back
Front/sides of neck
Face
Head/scalp
Abdomen
Glutes
Legs
Arms/hands
Feet
Is there anything you particularly enjoy or do not enjoy during massage? (i.e. I love face massage, I do not like my feet touched, I prefer not to talk during session) Or any particular requests for this massage? *
Prenatal Massage (skip ahead to 'Goals & Self Care' if this is not a prenatal)
How far along will you be at the time of your session?
Have you had a prenatal massage before?
選択を解除
Comfort Preferences - Please select all that you are comfortable with (note: we will always customize the session for your comfort & safety):
I agree that I have consulted or will consult my provider/midwife to make sure that massage is safe for me during this pregnancy
選択を解除
Goals & Self Care
What are your goals and expectations? (how do you want to feel DURING and AFTER your session) *
List any/all things you do for self-care AND how often (i.e. baths, rest, yoga, etc.):
Are you interested in self-care ideas/tips from me after your massage? *
Is there anything else you would like me to know about you, your body, or your preferences? *
Health History
Are you currently taking any pain medication? *
Please list any medical conditions (including skin related) or physical limitations you may have that you want me to know about:
Please list all allergies or sensitivities you may have:
Please list recent (within the last 2 years) - minor or major - accidents, injuries, falls, pain, or surgeries:
Additional
Please share anything else you would like me to know:
Policies and Acknowledgment By Client
By submitting this form, Client agrees to receive professional massage therapy services from Alexandra Strong, CMT (Therapist) of Atma Prema Wellness (DBA). Client agrees that all information on this form is accurate and complete. Client agrees to inform Therapist if any of the above information changes at any time. Client agrees to inform/communicate to Therapist of any changes needed for comfort throughout session. Client agrees to inform therapist any time they feel their well-being is threatened or compromised. Client understands that massage is not a substitute for medical attention, examination, diagnosis, or treatment. Client understands and acknowledges that Alexandra Strong is a Certified Massage Therapist that provides strictly professional, ethical, and non-sexual massage therapy services. Client acknowledges that ANY sexual behavior by the Client toward the Therapist, or Therapist toward the Client, is unethical, inappropriate and unacceptable. Sexual harassment is not tolerated. If the Therapist's or Client's safety feels compromised, the session will be stopped immediately. Client is scheduling this appointment at their own risk and accepts that neither Alexandra Strong of Atma Prema Wellness, nor The Yoga Branch (Hosting Facility), is liable for any injury, illness, or damages to person or property. If Client is under 18 years of age, this form must be signed by a parent or legal guardian.  

Client has read and agrees to Alexandra Strong, CMT's payment and rescheduling policy.
For more information visit www.atmapremawellness.org
By submitting this form and writing Your FULL Name in the space below, you acknowledge that you have fully read and accept the Policies and Acknowledgment section above: *
Thanks for completing this form! I will send another (very short) form 24 hours prior to your session as a way to check-in and confirm your session.
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