Email:

Address:

Occupation:

Best times for massage:

Emergency Contact Person:

Phone (Emergency Contact):

How did you hear about House of the Home?

What is your reason for seeking a bodywork?

Any other areas needing attention?

Consider the physical, mental, emotional, energetic.

Providing details of medical conditions and medications will help determine if it is safe for you to receive massage.

Do you have any allergies or sensitivities?

I will cross check any allergies with the massage oils, lotions and gels that I use.

Description of any injury/health condition:

Previous treatments for these injuries/health conditions (i.e. chiropractic work, physical therapy, medication etc.):

Please list any medications you are taking and any side effects that you experience.

Are you or could you be pregnant?

If yes, how many weeks?

Have you had a massage/bodywork before?

Can you describe it? What did you like or dislike about it?

Please use the space below to tell me anything else you'd like me to know.

What kind of pressure do you like? Do you tend to get cold/hot easily? What kind of music would you prefer to listen to during your massage?

COVID-19 Safety: At this time, clients are free to mask or not. HEPA filters are in all treatment rooms.

Cancellation Policy: Cancellation should be given at least 48 hours in advance. Appointments cancelled within 48-24 hours of the scheduled session are subject to a $50 cancellation fee. Appointments canceled in under 24 hours and “No Shows” are subject to payment-in-full. If you find a friend or loved one to take your place, fees are waived. PLEASE INITIAL HERE:

Clients arriving late will be charged for the full session and the session will end promptly at the scheduled time. PLEASE INITIAL HERE:

I hereby consent to receive a massage session from Bethiah Rosa for the basic purpose of relief from muscular tension. I understand that I am solely responsible to be of sound mind and body to receive treatment without experiencing physical or emotional injury. I agree to communicate to her any part of a session that does not feel helpful for the purpose I chose to receive massage. I have stated all known medical conditions and will update her on my health on all subsequent visits. I understand that Bethiah Rosa, as a Certified Massage Therapist, does not diagnose, provide prognosis, or prescribe and that our sessions should not be construed as a substitute for medical examination, diagnosis, or treatment. I agree to consult with my physician if I have any concerns with receiving massage therapy prior to attending a massage therapy appointment. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will still be responsible for full payment of the session. PLEASE SIGN HERE (example: /s/ Bethiah Rosa):

HOUSE OF THE HOME

INTAKE FORM

Initial Client Intake Form

Studio Sessions

In-Home Sessions

bethiah@houseofthehome.com