Client Intake Form | Massage with M

Full Name

Phone Number

Email

Date of Appointment:

Day

Month

Year

Medical History:

Do you have any medical history? If so, please list.

Are you taking any prescription medicines?

Do you have any injuries, recent or older?

Yes

No

If yes, please state what these are and year these occurred.

Reasons for Massage:

What areas of the body do you need most working on?

List any exercise you do, and how often?

What work do you do? State how this impacts your body.

Cultural Considerations:

Are there any Cultural considerations I need to be aware of?

Yes

No

If yes, please state. These could be any special considerations or rituals (e.g., prayer, music, areas to avoid)

Neurodiversity:

Do any of these apply to you? Autism, ADHD, PTSD, Dyslexia, Dyspraxia, Depression, Anxiety, Sensory Processing Disorder?

Yes

No

If yes, please state what applies.

If yes, please share any preferences or requirements to improve your experience, such as scents, sounds, lighting, words, triggers, or items needed. I may contact you before your appointment for more details.

By booking this massage, I agree to the following:

I realise that I am responsible for informing Massage with M of any condition or health issue that may affect this bodywork session.

I understand that Massage with M provides relaxation and therapeutic massage only. I accept there is no sexual services provided.

I accept that any disrespectful behaviour towards the therapist is not tolerated. If so, Massage with M reserves the right to terminate the massage at any time, with full payment expected.

If you’ve chosen holistic pulsing, you have the understanding that this is a fully clothed session.

Emergency Contact Details

How did you hear about Massage with M

If a referral, who referred you?