Here are 10 of the most important forms to use in your massage practice. Take the time to review your current forms to determine if you need to update them, such as make changes, additions or deletions. You also might need to create new forms. Also, eliminate duplicative information requests as most clients find them annoying.
I have listed the forms by when they are to be used, described the key elements, highlighted new aspects, and explored specific considerations (when applicable). While many of these forms can be electronic records, some clients might not be comfortable with technology and prefer to write on paper.
I recommend you have a New Client Checklist that you place in each client’s folder prior to their first session. The top section includes the client’s contact information, insurance information if applicable, and notes if a client has special needs. The next section of the form has two columns. The first column is a list of all of the documents you need to provide and the client management tasks you need to complete. The second column is to note the date when completed.
Start to fill out this form prior to the client’s first session, check off appropriate items during the check-in process of the first session, update during the client check-out process, and then update the form when any follow-up is done.
Use the Contact Information & Health History Intake form at the client’s first session and then annually to collect the names and contact information of the client, emergency contact and other health care providers.
This form often asks questions about the client’s experience with massage, their health history, such as current health concerns and medications, allergies and previous conditions.
An example of a thoughtful addition to an Intake Form is to ask clients their preferred pronouns. Using someone’s preferred pronoun demonstrates respect and client-centeredness. Guessing someone’s gender and pronouns based on their name or appearance is not always accurate and can communicate a potentially harmful message.
This is an informational brochure regarding sexual misconduct. It delineates clients’ rights and tells them how to protect themselves if their rights are violated. Items to consider include what to expect in the session, clients’ rights, warning signs of sexual inappropriateness, reactions to abuse, options for recovery, possible actions, registering complaints and legal recourse. You can download a free copy of a sample Bill of Rights that is part of the Client Brochure in this Sexual Assault Prevention Guidelines PDF: https://sohnen-moe.com/wp-content/uploads/2021/09/sexual-assault-prevention-v4.pdf
This form gets filled out at the beginning of the first session and gets completed after the session is over. First, ask clients for their long- and short-term wellness goals. After the hands-on part of the session is done, note what was found and the suggested treatment plan. Give a copy to the client so you both are aware of the treatment plan and goals.
The Informed Consent document serves to get a client’s permission before proceeding with the massage. Include a description of your approach to massage, a brief explanation of what to expect, benefits, potential consequences, a list of your credentials and areas of expertise, and a disclaimer that massage practitioners do not diagnose disease and massage is not a replacement for medical treatment.
During the treatment, verbally inform the client when moving to more vulnerable areas, such as the anterior neck, medial thigh and abdomen. Also, obtain permission from the client before varying from the agreed-upon treatment plan or using a new modality.
Ideally, clients will have read your policies before showing up at your office. Still, it’s wise to hand them a printed copy of the policies at the first session and then annually (or more frequently, if changes occur). Add the following to the end, “I have read these policies, I understand them, and I agree to abide by them.” Then leave space for their signature and date.
A policy statement is a useful vehicle for creating boundaries that encourage trust, safety and comfort. Policies explicitly define the expectations for both clients and practitioners. They make managing a practice easier, circumvent potentially awkward situations, provide means for conflict resolution, and demonstrate professionalism.
Policy statements can be designed in various formats resembling a letter, a page with bulleted items, or a combination of the two. Eight major areas to cover are: the type of service, training and experience; appointment policies; finances; expectations; personal relationships; confidentiality; and recourse policy. Written policy statements set a professional tone, even if you don’t have specific policies stated for every situation.
Periodically review your policies to see if any updates are needed. Perhaps there are specific populations you work with or specific conditions that require additional or expanded policies.
For example, if you work with trauma survivors who are in the active recovery process, affirm that while you must maintain confidentiality, clients aren’t bound to keep anything you say or do confidential. Consider an addendum to the confidentiality agreement that informs clients that the only other persons who know about your work together are your supervisor (who won’t be given the client’s name and identity) and the clients’ psychotherapists.
The COVID-19 pandemic has inspired many policy changes, and sometimes those policies change depending upon the current community health status (so don’t print out too many copies).
I recommend creating a special section in your Policy Statement (or a Policy Statement Addendum) that is titled something like “Health and Safety Protocols.” These protocols and policies can include requiring clients to fill out a COVID-19 Screening Questionnaire (see below) before each session, have their temperature taken when entering the office, washing or sanitizing their hands upon entering the office and after the session, wearing a face mask, and notifying the office if they or a family member tests positive for COVID-19 within 14 days of their visit your office.
In addition to specific policy updates, you might want to start the Health and Safety Protocols Questionnaire section with something like the following:
We ask that all patients abide by the following guidelines so we can maintain an optimally safe environment for all. Our standard policies cover client/practitioner expectations and interactions, appointments, fees, professionalism, confidentiality, security and recourse. We have also added a few policies to directly address COVID-19 concerns. We are actively following the CDC, the World Health Organization, and our local health agencies’ precautionary measures. COVID-19 has created a situation that continues to change, and we are actively following its course closely as we enact new measures to best ensure safety for our clients and healthcare practitioners.
Clients are asked to be cognizant of their own physical health. Please stay home if you become ill or have any flu-like/potential COVID-19 symptoms at all (e.g., fever, sore throat, cough, stuffy nose, body aches, nausea, loss of smell/taste).
Clients are asked to honestly disclose symptoms to best protect others during this sensitive time. Please inform our office if you or a family member tests positive for COVID-19 within 14 days of your visit to our office. If clients have been sick recently, had a fever recently, or are currently sick, we will reschedule their appointment to a later date. [As a side note, most practitioners are being flexible with cancellation fees if clients reschedule due to suspected illness.] Clients must be symptom-free for at least ten days before their appointments.
This form lists symptoms that clients or household members may have experienced in the past two weeks. It also has questions about household members, close contact of someone with a suspected or known case of Covid-19, travel and vaccination status. Be sure to include a line for clients to sign and date the form.[Download this free intake form to help screen out COVID-19]
This form asks the reason for their visit today, and any symptoms, such as pain, stiffness, bruising, numbness (often done by having a body chart on the form that clients can note the specific areas of those issues). It also often asks if there have been any significant health changes since their last visit, as well as any contact information changes.
A variety of options exist for charting a session, ranging from simple notes about the session to more formal notes (such as SOAP Charting) that include findings, treatment and response to the session.
Fill out a progress report (and give it to clients) after a specified number of sessions (depending on the actual treatment plan) and at least after every 10 to 15 sessions. The information to include is a brief summary of the client’s wellness goals, the initial findings, the treatment plan overview, progress to date and suggestions for future sessions.
Here are other forms you might need in your practice:
Cherie Sohnen-Moe is a recognized expert in the area of massage, business and marketing. She has worked in the massage field since 1978 and is the author of the textbook “Business Mastery” and co-author of “The Ethics of Touch” and “Retail Mastery.” She is also a MASSAGE Magazine All-Star, one of a select group of innovative therapists and teachers who are educating the magazine’s community of massage therapists in our print magazine, on our social media channels and online. She offers client intake and record-keeping forms on her website, sohnen-moe.com.
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