Pediatric Form (0-17)

Relax & Be Well, LLC

Therapeutic Massage and Wellness Coaching

About
Testimonials
Contact
Appointments

About
Testimonials
Contact
Appointments

Child's Name*

Child's Birth Date *

Parent/Guardian's Name*

Primary Phone *

Address*

Parent/Guardian's Email Address*

Child's Primary Care Physician, Clinic Name & Phone Number*

Has child ever received professional massage?*

YesNo

Reason for seeking massage therapy*

In order to better address your child's goals, please state your/your child's specific concerns and approximate date of onset *

Has child tried any other treatments for concerns listed above?*

YesNo

If yes, please describe

Birth History*

Biological childAdopted childFoster child

Was child born prematurely?*

YesNo

If yes, how many weeks early?

Were there any postpartum complications with the child?*

YesNo

If yes, please describe

Please list any current medications (prescribed and over the counter) or supplements the child is taking and what they are treating. Put 'none' if not taking anything.*

Has the child been diagnosed or treated for any of the following disorders/conditions? Please check ALL that apply.*

anxietyasthmaAttention Deficit/Hyperactivity Disorder (ADHD)eczemaAutism Spectrum Disorder (ASD)burn treatmentcancercerebral palsycystic fibrosisdepressiondiabetesDown's SyndromeHIV/AIDSPost Traumatic Stress Disorder (PTSD)COVID-19NONE APPLY

Any other medical conditions/concerns not listed above*

Has the child had any accidents, injuries or surgeries in the past 6 months?*

YesNo

If yes, please describe

Does the child have any allergies/sensitivities to oils, lotions or scents?*

YesNo

If yes, please describe

Please list your child's communication style *

verbalPECSword approximationsaugmentative deviceASLgestures

What methods does your child use to manage stressful situations (i.e. self-soothing techniques)?*

Does your child exercise or participate in sports? *

YesNo

If yes, please describe

Wavier of Liability and Consent to have Massage*

I agree to submitting intake forms online and waive all claims.I agree to hold harmless Relax & Be Well, LLC, of all claims, including Andree Strauss, her spouse, her heirs, her property and associations.I understand that my child's information will not be shared with anyone outside of Relax & Be Well, LLC without my written consent.I understand that if my child has a specific medical condition or specific symptoms, massage may be contraindicated. A referral from my child's primary care provider may then be required prior to their massage session. If my child experiences any pain or discomfort during their massage, the child or I will inform the practitioner immediately.I understand that the massage therapist cannot diagnose any medical conditions, but they can recommend seeing a medical doctor or medical specialist with any concerns.I have answered the above information to the best of my knowledge and will let the practitioner know if anything changes with my child's health history.

Cancellation Policy*

I understand that I will be charged 50% of my child's scheduled service fee if I cancel their appointment less than 24 hours before their scheduled time, with the exception of illness, emergency or inclement weather.I understand I will NOT be charged if I need to cancel within 24 hours due to COVID-19 symptoms in my child, myself or another member of my household.

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Thank you for submitting intake form. See you at your first appointment. If you need to schedule your first appointment Click the link below https://squareup.com/appointments/buyer/business/YHWCNL/relax-be-well-therapeutic-massage

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