General Intake Form-The Healing Tree

General Intake Form

Please take a minute to fill in the following info

Client Contact Information

First Name

Last Name

Phone Number

Birth Date

Address

Emergency Contact Information

Contact Name

Phone Number

Doctor Contact Information (Optional)

Contact Name

Phone Number

Other

How did you hear about us?

Issues to Address

If you have an injury or concern, please describe your situation below. (Your injury/concern & how long it has been since you first noticed it)

Treatment Goals

Past Treatments (If applicable)

Existing Conditions

Respiratory

Asthma

Bronchitis

Chronic Cough

Shortness of Breath

Reproductive

Gynelogical Conditions

Pregnancy

If you are pregnant, when is your estimated due date?

Family History

Cardiovascular Conditions

Respiratory Conditions

Medications

Please list any medications or drugs you are currently taking

Client Waiver Form

Please take a moment to read and initial the following information:

I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
I affirm that I have notified my therapist of all known medical conditions and injuries.
I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.
I understand that massage is entirely therapeutic and non-sexual in nature. If any inappropriate behavior is displayed, the appointment will end and I will be charged in full.
By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.
I am aware that the cancellation policy requires me to cancel within 24hrs. If that does not happen, I will be charged for that appointment (50% for existing clients or 100% for new clients).
I understand that Joleen is also a doula and may have to cancel my appointment with short notice because of unforeseen circumstances. If this happens, I will be offered $10 off to reschedule for the next appointment. Thanks for understanding!
I understand that if I book with an apprentice that I am working with a student who is a licensed massage therapist-apprentice working under the mentors superivsion. The mentor may assist during a session if necessary.

I read the client waiver form statement above and agree to all the policies