I will ask you to read and sign a copy of the form below before the first session.
My intention is to facilitate relaxation and healing in a safe environment. I request that you give me feedback with regard to the pressure that I use or if any techniques that I use make you uncomfortable. I also request that you take responsibility for alerting me to any physical or medical condition that could affect this massage. As a massage therapist I cannot diagnose medical conditions or prescribe any medications. Please see your physician or other health care provider for any medical conditions.
If you are uncomfortable for any reason, you may ask me to cease the massage and I will end the session. Draping will be used during the session. I will not engage in breast massage of female clients without the client’s written consent. Sexual behavior is not appropriate at any time during a massage and the session will immediately cease if I feel that behavior is inappropriate.
Payment is due at the time of the session. I request 24 hours’ notice of cancellation left on my voice mail, (915) 472-1525. If cancellation is given with less than 24 hours’ notice (except in the case of a medical or other emergency), you are responsible for full payment for the session. If I need to cancel with less than 24 hours’ notice (except in the case of a medical or other emergency) your next session is free.
I anticipate using some or all of the following massage techniques during our session:
(x) Craniosacral therapy
(x) Brain Curriculum
(x) Visceral Manipulation
( ) Other__________________
The areas that will be massaged are: ____________________ All except as contraindicated
The areas that will be avoided are: ____________________________ See intake attached
Specific indications and contraindications are: ___________________ See intake attached
Please sign below to indicate that you understand and agree to the terms listed above and that the information that you have supplied is correct to the best of your knowledge.
___________________________ _______________ _________________
Signature Date Lauren Davis
An individual who wishes to file a complaint against a massage therapist may write to: Texas Department of Licensing and Regulation, Massage Therapy Program, P.O. Box 12157, Austin, Texas 78711, (512) 539-5600, or www.tdlr.texas.gov to request the appropriate form or obtain more information.