Massage & Bodywork Intake Form

Please complete the following information clearly.

I understand that the services provided by Balanced Movement and Cassandra Studley are intended for general wellness, stress reduction, relaxation, and muscle recovery. Services may include manual techniques, soft tissue manipulation, assisted stretching, use of therapeutic tools, and application of pressure.

I explicitly understand that:

• These services are non-medical, non-diagnostic, and non-therapeutic in a medical sense.
• Massage therapy does not replace medical examination, diagnosis, or treatment.
• No medical advice will be provided, and no treatment of specific disease or injury is promised or implied.

I voluntarily consent to receive massage and bodywork services. I understand that:

• Physical contact is an inherent part of the service.
• Pressure levels may vary, and I have the right to request changes in pressure at any time.
• I maintain the right to modify or terminate the session at any time for any reason.
• My consent applies only to the areas of the body we have agreed to treat; I may decline work on specific areas.

I affirm that I have disclosed all known medical conditions, including but not limited to: recent surgeries, injuries, chronic conditions, pregnancy, skin conditions, contagious diseases, circulatory issues, or medications that affect pain perception, bruising, or blood clotting.

I acknowledge that failure to disclose health information may increase the risk of injury. I accept full responsibility for communicating with the therapist immediately if I experience:

• Pain or discomfort
• Dizziness or lightheadedness
• Numbness or tingling
• Emotional distress

I understand that Balanced Movement reserves the right to:

• Modify the treatment based on my health status.
• Decline specific techniques if they are contraindicated.
• Terminate the session immediately if it is deemed unsafe or inappropriate.

I understand that services may be refused without refund if I misrepresent my health history or if a health risk creates a safety concern for the therapist or client.

PLEASE READ CAREFULLY:

Massage therapy is strictly therapeutic and professional.

• No sexual services, sexual conversation, or sexually suggestive remarks will be tolerated.
• No inappropriate touch or advances toward the therapist will be tolerated.

Any violation of this policy will result in the immediate termination of the session. The client will be liable for the full cost of the scheduled session, and no refund will be issued. The client agrees that such behavior is grounds for a permanent ban from the premises and that the determination of such behavior is at the sole discretion of the therapist.

I acknowledge that, while massage is generally safe, there are inherent risks associated with bodywork, including but not limited to: temporary muscle soreness, bruising, fatigue, lightheadedness, redness, or emotional release.

I voluntarily assume all known and unknown risks associated with the services provided by Balanced Movement.

In consideration of the services received, I hereby release, waive, discharge, and covenant not to sue Balanced Movement, Cassandra Studley, their employees, agents, and independent contractors (collectively "Releasees") from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, whether caused by the negligence of the Releasees (to the maximum extent allowed by Vermont law) or otherwise.

This waiver applies to all past, present, and future sessions.

I agree to indemnify, defend, and hold harmless the Releasees from any and all claims, actions, suits, procedures, costs, expenses, damages, and liabilities, including attorney's fees, arising out of or resulting from:

• My failure to disclose accurate health information.
• My misconduct or violation of professional boundaries.
• Any third-party claims arising from my actions while on the premises.

I understand that the body responds differently to treatment and that results vary by individual. Balanced Movement makes no guarantees or warranties regarding specific results, including pain relief, recovery time, or performance improvement.

Client Recording: I agree not to photograph, video, or record the session or the therapist without express verbal consent.

Privacy: I consent to the therapist keeping internal notes regarding my sessions for the purpose of progress tracking and safety. I understand that Balanced Movement respects client confidentiality and will not share my records unless required by law or with my written consent.

I acknowledge the following policy regarding appointments:

• Cancellations: Must be made at least 24 hours in advance.
• No-Shows: Failure to arrive for an appointment without notice will result in a fee of 100% fee due.
• Late Arrivals: Appointment times are not extended for late arrivals. The session will end at the scheduled time, and the full fee will apply.
• Refunds: No refunds will be issued after a session has begun.

This agreement shall be governed by the laws of the State of Vermont. In the event of a dispute arising out of this agreement, the parties agree to attempt to resolve the dispute through good-faith negotiation or mediation before pursuing arbitration or litigation. I hereby waive my right to participate in any class-action lawsuit regarding these services.

If any provision of this agreement is held to be invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect. The waiver, liability, and indemnification provisions of this agreement shall survive the termination of the professional relationship.

I agree that my electronic signature acts as my legal signature and is binding. I understand this acknowledgment applies to this and all future sessions unless revoked by me in writing.

By signing below, I acknowledge that I have read and fully understand this document. I have had the opportunity to ask questions, and I sign this agreement voluntarily.