New Client Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Address * Date of Birth * Height * Weight * Occupation Have you had a Professional Massage before? Yes No Have you had an Ashiatsu/Barefoot Massage before? Yes No Massage Pressure Preference Light Medium Firm/Deep Not Sure What are your treatment goals for your session? Please list any current symptoms (Headaches, Stress, Pain, Numbness, Difficulty Sleeping, etc): Please list any diagnosis from a Doctor: Please list any past surgeries or injuries: Please list any medications you are currently taking: Do you have any allergies or sensitivities? * Are there any areas you prefer the therapist to avoid/not work on? Do you have any music preferences for your session? How did you hear about us? Policy Agreement * Cancellation Policy You will receive a confirmation email at the time of booking, and a text reminder 48 hours before your scheduled appointment. In order to cancel/reschedule your appointment at NO charge, I require a minimum of 24 hours notice. Within 24 hours of appointment or for no-call/no-shows, you will be charged 100% of your scheduled service. These charges will be based on the full, non-discounted rate of the service scheduled. Late cancellation due to emergency, illness, or inclement weather will generally not result in any missed session charges, but this is determined on a case-by-case basis at my discretion only. Late Arrival Policy Please arrive for your appointment at least 5-10 minutes prior to the scheduled starting time. This time is to be used to get settled, use the restroom if needed, and to check in with me and have our pre-session intake. All services offered have a specific time schedule and early arrival allows for a relaxed and unhurried experience. If you are running late, please call me at (865) 236-0175 to let me know as soon as possible. If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Regardless of the length of the treatment actually given, you will be responsible for payment of the "full" session. Out of respect and consideration to your therapist and other customers, please plan accordingly and be on time. Inappropriate Behavior Policy Massage therapy is for relaxation and therapeutic purposes only. There is absolutely no sexual component to massage whatsoever. Any insinuation, joke, gesture, conversation, or request otherwise will result in immediate termination of your session and a refusal of any and all services in the future. You will be charged the full service fee regardless of the length of your session. Depending on the behavior exhibited we may also file a report with the local authorities if necessary. Treat your therapist with respect and dignity and you will be treated the same in return. I have read and agreed to the cancellation policies above Your intake form has been submitted!