Personal Information

First Name

Last Name

Date of Birth

Month

Day

Year

Phone Number

Email Address

Address

Emergency Contact Name

Emergency Contact Phone

Reason for Today’s Session

Please describe your main concern, discomfort, or goal for today’s session

Medical Conditions

Please check any conditions that apply to you

Please explain any conditions checked above

Medications & Supplements

List any surgeries, accidents, or significant injuries (include dates if possible)

Pain & Sensitivity Awareness

Pain Level Today (0–10)

Pressure Preference

Light

Medium

Firm

Therapeutic / Deep

Sensory & Comfort Preferences (Optional but Encouraged)

Anything else that helps you feel safe and comfortable?

Please read and sign below.

I understand that massage therapy and bodywork are not a substitute for medical diagnosis or treatment.

I have disclosed all relevant health information to the best of my knowledge.

I understand I may stop or request changes to the session at any time.

I consent to receive therapeutic bodywork from Alfa Therapy LLC.

Signature

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Parent’s Signature if under 18

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Date

Month

Day

Year