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Client Intake Form
Please fill out the form below to the best of your knowledge and submit before your first appointment, thank you.
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Email
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Your email
Full Name
Your answer
Today's Date
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YYYY
Date of Birth
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YYYY
Phone Number
Your answer
Emergency Contact Name
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Emergency Contact Phone Number
Your answer
How did you hear about HOHM?
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Have you had massage/body work before?
Your answer
Please share your reason for seeking treatment today.
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I am trained in and offer the following modalities. Please check all that you are interested in.
Relaxation/General Massage
Deep Tissue Massage
Prenatal/Postnatal Massage
Abdominal Massage
Energy Work (Reiki and Intuitive Hands-On)
Sound Therapy
Do you have any acute injuries or chronic physical conditions that I should be aware of?
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Are there any mental or emotional stressors affecting your reality that might be important to share? (This is a safe, confidential space.)
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Are you allergic or averse to any types of massage or essential oils?
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Do you have any questions, fears, insecurities or concerns that I should know about?
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By typing your name and date below, you are signing this intake form and that you have provided, to the best of your knowledge, accurate information about your health history.
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A copy of your responses will be emailed to the address you provided.
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