Body Ambassadors

Client Intake & Care Agreement

Welcome. This intake allows us to understand your history, current needs, and intentions so we can tailor your session with precision and care.

Please complete thoroughly. All information is confidential.

01Client Identification

Full Legal Name*

Preferred Name

Date of Birth*

Phone Number*

Email Address*

Home Address

Emergency Contact Name + Phone*

02Current Care Intention

What brings you in at this time?*

Primary Areas of Tension or Concern

(e.g., low back, shoulders, hips, jaw, full body)

Pressure Preference*

Light

Medium

Deep

Unsure - guide me

Have you received Ashiatsu before?

Yes

03Health History

Please select any conditions that apply to you:

✓High / Low blood pressure

✓Heart condition

✓Diabetes

✓Cancer (current or history)

✓Blood clots / DVT

✓Varicose veins

✓Osteoporosis

✓Herniated / bulging disc

✓Sciatica

✓Recent surgery (last 6 months)

✓Pregnancy

✓Skin conditions (eczema, psoriasis)

✓Autoimmune condition

✓Nerve damage / neuropathy

✓Metal implants / hardware

✓None of the above

If you selected any condition above, please elaborate:

Are you currently under medical care for any condition?

Yes

Medications that may affect bodywork:

04Contraindication Awareness

Ashiatsu-specific standard - please acknowledge the following:

✓I confirm I am not currently pregnant.

✓I confirm I have no uncontrolled high blood pressure.

✓I confirm I have no recent fractures, acute inflammation, or open wounds in treatment areas.

✓I understand that if any of the above apply, my therapist may modify or decline Ashiatsu work in favor of a safer modality.

05Policies & Professional Agreement

Cancellation Policy

A minimum of 24 hours' notice is required for cancellations or rescheduling. Late cancellations may be subject to a fee.

✓I acknowledge the cancellation policy.

Professional Boundaries

Body Ambassadors provides therapeutic massage within ethical and professional boundaries. Any inappropriate behavior will result in immediate termination of the session.

✓I understand and agree.

06A Little More About You

How did you hear about us?

Instagram

Google

Word of Mouth

Physician Referral

Other

Care Pathway Interest (select all that resonate)

✓Athletic Recovery

✓Structural Maintenance

✓Stress & Nervous System Support

✓Prenatal / Postpartum Recovery (non-Ashiatsu)

✓Just Exploring

Would you like to join our private email list?

Yes, I'd like updates

No, thank you

07Digital Signature

Type Your Full Legal Name*

Date*

Body Ambassadors · Kathleen Kraft · 561-445-0472