New Client Intake – Jane's Therapy

Personal Information

Date

Name *

Full Address

Email

Phone Number *

Birthday

Occupation

Referred By

Where did you hear about us?

Other

Health History

Recent or past injuries?

Recent or past surgeries?

Medical Conditions

Are you pregnant?

Allergies

For Today's Bodywork Session

I prefer:

Really focused body work on specific trouble areas onlyFocused work on trouble areas and light work elsewhereA well balanced full body massage w/ no real specific areas

Areas to avoid or that you do NOT want worked on

Service & Session Time

Service *

Massage Enhancements ($10–30)

For Today's Session

I prefer:

Very minimal talking so I can relax my mindSome feedback along the way is preferredFeedback, once I'm clothed, after the session onlyNo extra feedback/chatter, just quiet relaxation

Pain & Discomfort Areas

Tap on the body diagram to mark areas where you are experiencing pain or discomfort.