Medicaid Waiver Client Intake Form Client Name * First Name Last Name Preferred Name Date of Birth * MM DD YYYY Sex * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Client Occupation (if applicable) Client Email (if applicable) Client Phone (if applicable) (###) ### #### Preference for In-Home or In-Office? In-home In-office No preference Days and times that work for you to receive massage therapy MEDICAID INFORMATION: Medicaid Number (if known) Case Manager/Service Coordinator (if applicable) Case Manager Email Waiver Type CES CHRP SLS Other Unknown PARENT, GUARDIAN OR EMERGENCY CONTACT: Name * First Name Last Name Relationship to Client * Phone (###) ### #### Email * Names of siblings, pets, caretakers or other household members we should know about: Client hobbies, strengths and other things we should know about them: MEDICAL HISTORY: Hospitalizations, Surgeries, other Traumas: Current medications, supplements, herbs or remedies: Allergies Primary Care Physician: Areas of chronic tension, pain, continued medical challenges: BODYWORK INFORMATION: Has this person had massage/bodywork before? If so, when last? Likes or dislikes for massage therapy: ie, pressure preference, places that are ticklish, etc.? What goals do you have in receiving bodywork? Text Area By signing below, you consent to treatment and agree to the following: If I experience any pain or discomfort during this session, I will immediately inform my therapist so that she can adjusted to my level of comfort. I understand that deeper bodywork may result in sore muscles or tenderness following the massage and will contact Bonnie Eason or my therapist if I feel I am excessively sore or in pain. I can end the session at any time without giving a reason. If I am dissatisfied with the services, I can discuss this with my therapist or Bonnie Eason for modification of treatment or to request a different therapist. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said during the session should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep my therapist updated as to any changes in my medical profile and understand that there shall be no liability on their part should I fail to do so. My therapist will keep our work together confidential with the exception of these special situations: if they believe I am in imminent danger of hurting myself or another person; a child, elderly or disabled person is being abused; they are presented with a legitimate court order to present testimony in a legal proceeding. I may direct my therapist to share information with whomever I choose and can change my mind and revoke that permission at any time. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. If arriving or being ready for the session late results in the session starting late, the session will still end at the scheduled time. Hold Harmless Agreement: I hereby agree to indemnify and hold harmless Bonnie Be Bodywork, LLC and its independent contractors from any loss, liability, damage or cost they may incur due to any claim made against them arising from the provision of therapies to me, or in any way resulting from, arising in connection with, or related to any therapies performed by her to me. Understanding all of this, I give my consent to receive care. I understand that my typed name serves as a signature. * Yes Typed Signature * Thank you! We will be in touch soon.
