Inner Soul + Stillness Massage

Intake Form

A sacred space for stillness, release, and reconnection to the rhythm of your heart.

Client Information

First name

Last name

Email

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Emergency Contact Name + Number

Occupation

WELLNESS BACKGROUND

1. Are you currently taking any medications?

2. Do you have any allergies or sensitivities to scents, oils, or massage products?

3. Have you received bodywork, massage, or energy healing before?

SOULFUL REFLECTIONS

5. Are there specific emotions, patterns, or energies you wish to release?

6. Do you currently practice meditation, breathwork, or spiritual rituals?

7. How do you currently connect with your body, mind, spirit, and heart?

8. Are there areas of your body where you often hold emotion or physical tension?

9. What intention or energy would you like to invite into today’s session?

ENERGETIC & EMOTIONAL AWARENESS

10. Are there any recurring emotions or life themes you’ve been navigating recently?

12. Are there areas of the body or types of touch you prefer not to be worked on?

INTEGRATION & POST-SESSION CARE

I understand that massage and energy work are complementary to, not a replacement for, medical care

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

I give consent for the practitioner to use intuitive, energetic, and therapeutic methods aligned with my stated intentions.

I understand that all information shared is kept confidential.

I agree to communicate any discomfort, boundaries, or preferences at any point during the session.

I acknowledge that this session may include energy work, sound healing, or aromatherapy as discussed.

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