I will take the time to prepare and research in order to make the most out of our time together. Please submit intake at least 48 hours prior to your session.

Massage and Movement Intake

First Name

Address

Email Address

Last Name

Phone

Date of Birth

Have you been hospitalized in the last 12 months?

Yes

Are you currently suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate

What are your goals and/or intentions for this session?

What has been your experience with massage and bodywork in the past? What did you like or dislike? What massage modalities are you familar with and/or want? (you can check my modality list on the website if you are unsure :)

What types of physical movement and/or positions regularly appears in your work, daily life or recreation?

What substances are you currently taking? (Please include any/all herbs, prescription medications, supplements, recreational drugs) homeopathic remedies)

Are there any aromatherapy fragrances and/or oils that you would not like used? If yes, please list below

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!