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Intake Form

75 min • Breath • Zenthai Shiatsu • Nervous System Regulation

Please complete this short intake before your session.

Full Name

Mobile Number

What would you most like support with today?

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Anything you’d like me to focus on or avoid?

Is there anything medically relevant I should know before providing bodywork?
Examples: current injury, recent surgery, pregnancy, blood pressure concerns, blood clot history, skin conditions, major health conditions or relevant medications.

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B

Preferred pressure

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Consent + Professional Boundaries

This is a professional massage and bodywork service. Please respect the practitioner, treatment space and professional boundaries at all times.

Sexual requests, inappropriate touching or behaviour will result in the session being ended.

You may ask to change or stop any technique at any time.

Location

Your session will take place at Revival Room Yandina.

The exact address and arrival details will be provided on the day of your appointment.