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? If yes, please list.

Are there any past or recent injuries, trauma, stress, emotional experiences, nervous system challenges, or significant life events that may be relevant to your wellbeing or sessions?

If you selected “I’d prefer to discuss this in person” and feel there is a lot to talk through, please be aware additional time may be needed to ensure you feel heard and supported, while also respecting appointment times for clients after you. You may wish to book a longer session or add a Space2BHeard session add-on to allow extra time and space for conversation and support.

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

This can also include injuries or events from childhood through to today, it's all valid.

Reasons for Booking Your Session

If applicable, 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 bodywork session, I agree to the following:

I realise that I am responsible for informing Unify Body and Being of any condition or health issue that may affect this bodywork session.

I understand that Unify Body and Being 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, Unify Body and Being reserves the right to terminate the massage at any time, with full payment expected.

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

Emergency Contact Details

How did you hear about Unify Body and Being

If a referral or networks, who referred you?