Esalen® Massage Intake Form

We take your privacy very seriously.
Your personal information will never be shared with any outside party.

*Would you prefer that your massage therapist wears a mask during your session?

Your Contact Information
No preference	Yes, please
*First Name
*Last Name
*Email
*Address Street 1
*Address Street 2
*Address City
*Address State
*Address Postal Code
*Address Country
*Mobile Phone	( ) -
*Home Phone	( ) -

Your Emergency Contact
*Emergency Contact Name
*Emergency Contact Phone	( ) -

General Information
*Birthday
*What gender do you identify with?
*Occupation

How did you hear about us? (check all that apply)*
Internet Search	Billboard	A Look At Asheville (hotel book)
Trip Advisor	Rack Card/Flyer	Mountain Xpress (newspaper)
Facebook	LEAF (festival)	Received a Gift Certificate
Yelp	Asheville Community Yoga	Map of Asheville
Referred by Friend/Word of Mouth (Who referred you?):
Other (please list):

What are your goals and intentions? (check all that apply)*
Pain Relief	Boost Immune Function	Healing
Relaxation	Inner Exploration	Curiosity
Sleep Better	Mental Focus/Meditation	Emotional Release
Therapeutic	Mind/Body Awareness	Expand Knowledge of Massage
Other (please list):		Increase Ability to Receive Healthy Touch

*What tools, practices and activities do you use to relieve stress and maintain your wellbeing?

Health Questionairre
The following questions help us to address concerns and assess if you have any conditions that might be contraindicative to massage. Please check all that apply and explain if necessary.

Do you have any of the following conditions? If so, please refer to our Contraindications page.*
Open Scrapes, Cuts or Wounds	Contagious Disease	Contagious Skin Condition
None

*Allergies and/or sensitivity to oils, foods or scents:

*Major Surgeries and/or Injuries (include approximate dates):

*Medications you are taking and the conditions they are related to:

*Are you pregnant? Yes No
*When is your due date? (MM, YYYY)

*Have you ever experienced abuse?
Emotional Abuse	Mental Abuse	Physical Abuse	None

*Where in your body do you hold tension?

*Other health concerns mental/medical conditions and/or phobias

Your Massage Experience

*Have you ever had a massage? Yes No
*If so, what styles?

*How frequently do you receive massages?
*When was your last massage? (MM, YYYY)

*What areas of your body should your massage therapist AVOID?
Abdomen	Face	Glutes
Other (please list and explain):*

*What would you enjoy during your massage?
Lighter Touch	Stretching	Essential Oils
Firm Pressure	Energy Work	Music
A Variety of Pressures	Verbal Guided Relaxation	Silence

*What areas of your body would you like your Massage Therapist to FOCUS more attention on?

Release of Liability

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so.

If I make any sexual advancements or innuendos the session will be terminated immediately without a refund.

I agree to give 48-Hour notice if I choose to reschedule or cancel an appointment for any reason other than a family emergency or sudden illness. If I cancel without 48-hour notice or do not show up to my appointment I agree to pay the full cost of the massage session.

By submitting this form I affirm the accuracy of the information I have provided and understand and agree to the policies above.

* I Agree