Massage + Movement Forms
Save time at your session. Download my policies and initial intake forms, print, sign, and bring to first visit.
The MVA form is needed only for those client's making Motor Vehicle Accident Claims via their insurance.
MVA's, if you are making a PIP claim have a doctor's prescription with all ICD-10 codes before our session.
At BREATH + GRAVITY I understand that unanticipated events occur in everyone's life. I place no judgments on the need for a client to cancel a session. However, in my commitment to provide a unique and outstanding massage experience to all of my clients and out of consideration for my time, I have adopted the following policies:
ARRIVAL TO YOUR MASSAGE
Please arrive for your appointment on time with all paperwork filled out. This ensures that we can chat about current issues and session goals and get you on the table in a timely fashion. All massages have a specific time schedule. Your session time may include posture assessment, initial intake conversation, massage, and post-massage reassessment.
Please note that I work from my home. There is no waiting room. Clients who arrive early may have to wait on my porch or in their car until I have finished the previous session.
If late arrival is inevitable, your service(s) may be shortened in order to keep on schedule. The original treatment time will be charged.
CANCELLATION & NO-SHOW POLICY
Please provide at least 24 hours notice if you need to reschedule or cancel a treatment. This gives me enough time to try to fill the slot. No-shows/Late-Cancels affect my ability to serve my clients and make it difficult to run my business.
Client will be billed for entire cost of the treatment or in cases where client has purchased a package of several sessions, one of the sessions will be automatically subtracted from the package. The only exception to this policy is hospitalization of the client. Thank you for your understanding.
Prior to each massage session, the treatment plan will be discussed with you. At your first visit with me you will receive a copy of these massage therapy policies and will be asked to sign the consent stating that you have read the information, understand it, and agree to comply with the professional massage therapy policies and procedures. Clients whom I have not seen for at least a year will be asked to fill out this form again. At each subsequent visit a simple Health Update form is all that is required.
SCOPE OF PRACTICE
Dawn Larned is a licensed professional and holds to the highest standards of the American Massage Therapy Association.
Massage Therapy is a profession in which the practitioner applies manual techniques, and may apply adjunctive therapies such as: hydrotherapy, exercises, and stretches, with the intention of positively affecting the health and well being of the client.
Massage Therapists do not diagnose or prescribe for medical conditions. Some conditions may require a doctor’s release.
RESPECT FOR CLIENT NEEDS AND BOUNDARIES
I am happy to adjust pressure, temperature, and musical volume, work longer on an area or move on if you request it.
The client may choose to leave on as much clothing as needed for comfort, refuse any massage methods, stop massage at any time, and leave the session.
The client will always be modestly draped. Only the area being massaged will be undraped. The client will be kept informed of the area to be massaged.
Occasionally, an emotional response to massage occurs. If this happens, it is ok to express the feelings in my safe, nonjudgmental environment. You may ask me to remove my hands so that you can process the emotions, or you may request privacy and end the session. You are in control.
PROFESSIONAL BOUNDARIES & CONFIDENTIALITY
Requests for sexual activity will not be tolerated, will be viewed as solicitation, and reported to the proper authorities. The session will be terminated immediately and the client will not be rescheduled if this occurs.
The discussion between the massage therapist and the client is confidential.
I am happy to listen to your conversation and share my professional expertise. Some modalities/sessions may require more verbal interaction between therapist and client.
I will massage minors only with the written consent of a parent or legal guardian.
EXISTING AND NEW MEDICAL CONDITIONS
It is the responsibility of the client to keep the massage therapist informed of any medical treatment currently being taken, and to provide written permission from the physician, chiropractor, physical therapist, etc., allowing massage therapy.
The client must also keep the massage therapist informed of any changes in health conditions.