Name *

First Name

Last Name

Phone

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DOB *

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Services Requested (check all that apply) *

Massage Therapy

Somatic Therapy

Psychotherapy

Health & Wellness Coaching

Equine Somatic Work

Private Yoga

Policy

Please read and then check the following individual policies. By checking and signing this intake/consent form, you acknowledge that you have read, understand and fully agree to adhere to all the policies listed below.

Scheduling:- I understand that if I cancel or reschedule with less than 24 hour notice, I will be charged a 50% cancellation fee. I also agree that if I am late for my session, the session will still end at the originally scheduled time but full service fee will be charged.

Payments - I understand that full payment is due at the time of service.I I understand that accepted forms of payment are cash, credit/debit card, and electronic payments (e.g., Venmo, PayPal) AND Health Savings Plan that use a “card” for payment. I understand Laura Wheeler does not direct bill insurances.

Illness: If you are feeling unwell (fever, cold, flu, COVID-19 symptoms), we ask that you reschedule your appointment to prevent the spread of illness. Rescheduling fees will be waived if rescheduled with more than 24 hours’ notice.

Professionalism: Our massage therapists adhere to a strict code of professional ethics. We ask that all clients also maintain respectful behavior during their sessions. Any inappropriate behavior (sexual innuendos, sexual harassment, requests for sex or genitalia massage, “happy-endings”, etc.crude or sexually alluding comments will not be tolerated, even as a “joke”) will result in immediate termination of the session, and full payment will still be required.

Draping and Comfort: Modesty and Comfort: Our therapists are trained to ensure your comfort and will always work to respect your boundaries. You will be properly draped during your massage, with only the area being worked on exposed. Please feel free to communicate with your therapist at any time if you are uncomfortable or would like adjustments to pressure, temperature, or music.

Disclosures: Clients are encouraged to discuss any preferences or concerns with the therapist prior to the session (e.g., pressure, specific areas to focus on, allergies, etc.).

Confidentiality: Client Confidentiality: All client information, including personal details and health history, is kept confidential and will never be shared without the client’s consent, except as required by law.

Accessibility: We are committed to making our services accessible to all clients. If you require special accommodations, such as wheelchair access or other support, please let us know in advance so that we can prepare appropriately.

Consent: All clients must give informed consent to the massage therapy session before the treatment begins. You have the right to withdraw consent at any time during the session.

Right to Cancel: Laura Wheeler, LMT and Untethered Healing Arts, reserve the right to cancel any appointment or session in the event of an emergency, illness, or if the therapist is unavailable. In such cases, we will notify you as soon as possible and offer you an alternative date and time for your session.,

Date

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