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Client Intake Form

Welcome to In Touch Massage. Please complete this client intake form fully and accurately prior to receiving massage therapy services. The information provided is used to assist the massage therapist in determining appropriate techniques and any necessary modifications to support safe and effective care. All information is confidential. If you are uncertain how to answer any question, please indicate so or ask your therapist for clarification.

First name

Last name

Phone

Birthday

Month

Day

Year

Email

Preferred Method of Contact

Text

Email

Call

Address

Referred by:

Gender

Female

Male

Non-Binary

Prefer Not To Say

Have you received professional massage/bodywork previously?

Yes

No

Pressure Preference

Light

Medium

Firm

Other

What are your goals and expected outcomes for receiving massage?

List and prioritize current symptoms and issues:

Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?

Yes

No

Occupation

How may your job negatively impact your body/muscles?

Physical History – recent or recurring injuries, surgical history, or chronic conditions that may affect posture or movement:

Please check any conditions that currently apply to you or may be relevant to your massage session. This information helps your therapist provide safe and appropriate care. All information is confidential. If unsure, please check the box and add details below.

Consent Acknowledgement

I understand massage therapy is for relaxation, relief of muscular tension, and general wellness, and I will communicate any discomfort during the session.

I understand massage therapy is not medical care and the therapist does not diagnose, prescribe, or treat conditions.

I agree to provide complete and accurate health information and report changes before or during the session.

I understand inappropriate or sexually suggestive behavior will result in immediate termination of the session.

I understand the therapist may refuse or discontinue services if massage is contraindicated or otherwise inappropriate.

Liability Acknowledgement

I acknowledge that massage therapy involves the manipulation of soft tissue and may result in temporary soreness, discomfort, or other physical responses. I understand that it is my responsibility to provide complete and accurate information regarding my health history, medical conditions, injuries, and medications, and to inform the massage therapist of any changes in my health prior to or during each session. I agree to communicate any discomfort or concerns during the session. I hereby release and hold harmless the massage therapist and business from any liability for injury or adverse effects arising from massage therapy services, except in cases of gross negligence or willful misconduct.

Signature

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