This form helps me determine if mobile massage is a safe and appropriate option for both client and therapist.
Basic Information
1. Full name: {"type":"text","name":"__generic","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
2. Phone number:{"type":"text","name":"__generic","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
3. Address where the service will take place:{"type":"text","name":"__generic","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
4. Preferred appointment days/times:{"type":"textarea","name":"__generic","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"Please list your preferred days and times Monday-Friday 930am-2pm, please leave details if Saturday’s are your only availability, Saturday appointments are a case by case basis only and very limited"}
Home Environment & Space Requirements
5. Do you have a room or open space large enough for a massage table (at least 8 ft × 4 ft) and a stool?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes \nNo \nUnsure – need help assessing"}
6. Is the space free of excessive clutter or hazards?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
7. Is the space quiet and free of interruptions?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
8. Will the massage be performed on the main level of the home (no more than one flight of stairs)?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
If no, please explain:{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
9. Is there easy, safe parking available nearby? (driveway/street/complex)
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
If no, describe the parking situation:
{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
10. Is the walkway/entrance well-lit and free of hazards?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
11. Will temperature control (heat/AC/fan) be available to maintain a comfortable environment?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
Household & Safety Considerations
12. Are there pets in the home?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
If yes: Type(s): {"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
Will they be secured in another room for the duration of the session?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
13. Does anyone in the home smoke inside the house?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
(Note: For health/safety reasons, mobile services cannot be performed in a smoking environment.)
14. Will any other adults be present in the home during the session?
*Please note that BIOLOGICAL MALES requesting mobile services, must have a SPOUSE or LONG TERM PARTNER present in the home at time of service. If not, mobile massage will not be the right fit, and you are welcome to come to my home studio space.*
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
If yes, please list who they are (family, partner, roommate, etc.):
{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
15. Will any children be home during the session?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
If yes, will another adult be responsible for supervising them?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
16. Are there any security systems, cameras, or smart devices recording inside the treatment space?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
(For privacy, cameras must be turned off in the treatment area.)
17. Has your home ever experienced issues with aggressive pets, harassment, or unsafe visitors?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
If yes, please explain:
{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
Client Experience & Expectations
18. Have you received professional massage therapy before?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
19. Have you ever received a massage at home before?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
20. What type(s) of massage are you interested in? *please note- at this time I am not yet offering lymphatic or post surgical massage, but it will be available in the near future!*
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"☐ Prenatal\n ☐ Postpartum\n ☐ Lymphatic drainage\n ☐ Post-surgical\n ☐ Swedish/relaxation\n ☐ Deep tissue\n ☐ Other:"}
{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
21. Are you comfortable with the therapist setting up and working in your home environment?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
(Some clients prefer studio appointments if they feel unsure.)
22. Are you aware that sessions must remain professional at all times, and inappropriate behavior will result in immediate termination?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
Safety & Accessibility
23. Does your home have any accessibility issues I should be aware of (steep stairs, long walkways, gates, restricted access, etc.)?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
If yes, describe:
{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
24. Do you feel safe having a provider enter your home, and can you provide a safe, secure environment for me?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
25. Do you consent to providing a valid ID prior to the first mobile appointment for safety verification?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\n No"}
26. Is there anything else you feel I should know about your home environment to ensure a safe and comfortable session for both of us?
{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
