NEW CLIENT APPLICATION

NEW CLIENT APPLICATION

This practice has limited availability to accept New Clients. New Clients are accepted based on availability, with priority being given to professional referrals inside our network. In order to serve you better please complete this form and provide some information about yourself and how we may be of service in the future to see if we are a good fit and help us get to know you better!
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
How were you referred?*
What is your primary reason for seeking an appointment *
Briefly describe any current medical conditions and any physical, mental, or emotional conditions/symptoms you are currently experiencing that you feel may be supported with Massage and Energy Work. *
You can visit the website www.littletonmassage.com to see our areas of specialty.
What is your previous experience with Massage Therapy and Energy Work?*
Prior massage and energy experience is not a prerequisite, but it helps us know where you’re coming from.
Are you currently taking any medications/supplements? *
Please list all prescriptions, current medications, and supplements.
Where do you hold tension/stress in your body?

How would you rate your sleep?*

	1	2	3	4	5

1 is Needs Support, 5 is Fantastic

How would you rate your current state of health? *

	1	2	3	4	5

1 is Worst, 5 is Best

How would you rate your current self care?*

	1	2	3	4	5

1 is Needs Focus, 5 is Fantastic

How would you rate your current diet/exercise? *

	1	2	3	4	5

1 is Needs support , 5 is Fantastic

How would you rate your current water intake?*

	1	2	3	4	5

1 is I don’t drink water , 5 is I am super hydrated

Do you have any allergies or sensitivities to scents or lotions?*

YesNo
If yes, please list.
What are your long term wellness goals?*
Is there anything else you would like us to know about you prior to your appointment?*
Please include any recent/major life changes, losses, and current challenges in this section.
Are you "all-in?" and ready to take the next steps in your life, work, relationships, physical, mental, emotional, and spiritual well being? *
Thank you so much for taking the time to provide this information. We are currently accepting applications for 2023. Upon availability and approval we will get back to you with your next steps for scheduling an appointment or professional referrals that may be helpful if we are unable to accommodate you as a client.

Due to limited availability and a high volume of new client requests you may be added to our Waitlist or referred to other Professionals in our trusted referral network. We typically review new client applications on a monthly basis, and due to the high volume we receive are not always able to answer each one personally. Please ensure that the contact information you provide including email and phone number are correct as we may need to verify them as part of our intake/follow up process.
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