An intake is a valuable and necessary tool for any massage therapist.
When I started my practice more than 25 years ago, I quickly learned that this information was vital because an intake form hugely benefited my client’s treatment, built trust between the client and myself—and therefore, the success of my practice depends on it.
I have included a general outline for your own intake paperwork in this article so that you can see what a basic intake form should include.
You need an intake form to rule out contraindications for the massage treatment, make your client aware of their rights, and provide a HIPPA statement to be signed and kept on file.
You might be unaware that the state you practice in requires that you keep records for each client and you may need to bring yourself up to standard.
In my state, Idaho, our professional laws state that as a licenses practitioner I must obtain voluntary and informed consent from the client, or written informed consent from client’s legal guardian, prior to initiating the treatment plan. Verbal statements do not suffice.
Above all, the more comprehensive way to have a better picture of your client’s health is to have paperwork available for each client to fill out.
This can be a one-page process or up to four or more pages of information.
A one-page intake form should provide basic information about your client, with a signature capture, HIPAA statement, and possibly a small body chart to mark on. For private practice, the greatest benefit comes from using a full health history form.
There are on-line companies that provide intake forms; however, I have found that they are not tailored enough for my practice. I do keep my clients’ files on line now, but I transfer the written intake form to the on-line charting system after the initial appointment with my client.
Build Trust with Your Intake Form
Your intake process and paperwork should have a flow much like giving a massage. You are actually outlining the massage you are going to give before you start. This communication builds trust with the client as it helps you to be seen as the healthcare professional you are, and tells the client you are detail-oriented and in compliance with legal requirements.
- There is an opening touch and introduction: Basic information section.
- Warm up techniques: Define your client’s expectation of the massage that day.
- Going deeper into the tissues or utilization of specific outcome basic techniques: Health-related concerns and contraindications.
- Targeted-area treatment: Body chart diagrams.
- Maintaining the comfort and client preferences: Safety disclaimer and HIPAA signature pages.
- Closing strokes and ending touch: Making sure all needs were address and the requests for certain outcomes were met.
- Checking in with client after the massage to see how they are feeling: S.O.A.P. charting.
Once you complete an intake process with a client, the actual massage flow and outcome needs that your client has requested will have automatically been established for you.
I like to discuss with the client what I have found and gain clarification of needs and wants. I then ask the client if the massage treatment outlined is what they are wanting that day.
If not, we can adjust the flow or process so that I can best meet their expectations. The power of rescheduling is in the process of walking your client through their massage before treatment—not during treatment.
In some cases, the only option you have to glean this important information is to ask and have confirmation of validity for treatment.
Make sure that you include questions about contraindications, what massage can and can’t do for clients, and if it is all right for you to work on them today.
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Your Page-by Page Guide to an Intake Form
1. Page or Section 1: General data and contact information. This page includes such basic information as name, email, address and physical address.
This page also includes expectation questions, such as “What results are you wanting from the massage session today?”
2. Page or Section 2: Health-related questions and contraindications. With this page, you are making sure that the massage today is a safe form of treatment for your client by prompting the client with specific questions.
The three biggest things to observe and make note of are: circulation, skin and fever.
Example categories: acute inflammation, bone and joint deterioration, nerve issues and impingements, autoimmune factors, specific areas of complaint, pregnancy complications, blood clots, metastasized cancer, infections, allergies, contagious illness (bacterial/viral sickness) or anything that you can spread or can be spread to you by touching their body.
These and other factors can change what you can apply to the client’s body or even if they can receive massage at this time.
It is your job to understand the applicable pathology or physiology contraindications and determine effective treatment or even if massage is contraindicated for this person.
3. Page or Section 3: Body diagramming. Include a visual representation of the client’s body needs. X marks the spot.
This is important because your idea of shoulder pain and the client’s idea of the shoulder might be different.
4. Page or Section 4: Consent for massage and disclaimer.
This area tells the client in plain language the extent of massage therapy as a health treatment.
What you do not offer with massage; not chiropractic, non-sexual touch. This section also includes space for the client’s signature and date.
This statement is required to be part of the health care system or to provide treatment application to someone. The landmark act (HIPAA) was passed in 1996 and became law in 2001.
S.O.A.P. notes remind you what to do with each person, preferences and successful techniques. This is part of your job even when working with people for relaxation or therapeutic treatment.
I include a pre- and post-pain level note for each session. In my mind, effective treatment should create a four-point decrease in pain (using a 10-point scale). If it does not, I use my treatment notes to alter my approach for the next session.
When I find what creates the four-point decrease, I know that the treatment I provided was successful. That is the session and techniques to use with this person.
You will do yourself and your client a disservice if you don’t remember what you did during the last session. Writing it down is the only way to know what to do for each individual client you work with.
Primary Assessment Tool for Massage Practices
Utilizing a massage therapy intake form creates opportunities to expand your skills. It points the way to how and why you reorganize the massage flow and structure. It helps you tailor your skills around what the client is requesting or requires for positive change from the session.
It gives you the framework to begin building each session to the specifications of your client.
Armed with all the above information, intake forms and note-taking can be the tools you need to run a successful practice. As a teacher, I tell my students that once you leave massage school and I am no longer there to guide you, these forms will become your teacher.
A massage therapy intake form is a powerful means of building trust in the therapeutic relationship. Simply learning to utilize an intake form can be the positive change you are looking for to help you become the professional massage therapist you want to be.
About the Author
Amy Bradley Radford, LMT, BCTMB, has been a massage therapist and educator for more than 25 years. She is the owner and developer of Pain Patterns and Solutions Seminars CE courses (ppsseminars.com). She has authored several books, including Defining Expectations for Massage Therapists.
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