This intake form may be a little more extensive than what you've been asked to fill out for prior massage therapy. I appreciate you taking time to fill it out. Everything on here provides valuable information so that I can deliver safe, compassionate, comfortable and effective outcomes for any and all sessions. 

Please do your best to complete your intake at least 24 hours prior to your appointment. While it is possible to complete it in office before your first session, if you need to do so, this will take some time away from your hands on treatment. 

I have taken the required additional training for WA state to do full therapeutic chest and breast massage and pelvic floor massage. This form is included for ALL new client intakes since I offer these treatments in my practice (described below) when it is indicated and desired by the client. Please complete this form even if you don't wish to receive these types of treatments.

Both written and verbal consent is required for treatment of these areas. If you opt to receive full therapeutic chest / breast massage and/or pelvic floor treatment massage, I will check in with you at the beginning of each subsequent session to confirm your preferences and a second time during the session before working on that particular area. You can change your preferences at any time for any reason. 

I voluntarily consent to receive full body, therapeutic massage from Cheryl Tjulander, LMT, with the specifications listed and chosen below.

I am aware that (1) the intent of the massage is therapeutic and not sexual, and (2) I have the right to:

• discontinue the entire massage session, or any part of the session, at any time and for any reason
• request the massage to be given through a drape rather than directly on my body, at any time for any reason
• provide a witness who will be in the room with me while I receive massage

DESCRIPTIONS of BREAST & CHEST MASSAGE for both men and women

• full chest/breast massage, undraped: done undraped on the full chest and breast and includes the chest wall and breast tissue. While nipples & areolae are not specifically treated, they are touched with broad, sweeping strokes. This is an example of full undraped breast massage. I use these same strokes, with possible slight variation in order.. https://youtu.be/HRz9XTXktQc?si=IEBNhNTX0q77HICB.     
• simple chest massage, draped: done with breasts/chest draped. Soft breast tissue is avoided. Focus is on muscles attached to sternum and ribs.

THERAPEUTIC RATIONAL FOR CHEST & BREAST MASSAGE includes but is not limited to: supporting breathing, blood and lymph circulation healthy posture, lactation and the immune system, treating neck, rib or shoulder injuries, mobilizing scar tissue, preparing for and/or recover from surgery.

DESCRIPTION of PELVIC FLOOR MASSAGE: massage of muscle attachments located on the pubic bone and the pelvic bones located between the legs. Genitals and the perineum are always avoided. This massage may be done thru the drape or on skin.

THERAPEUTIC RATIONAL FOR PELVIC MASSAGE, including the sacrum, coccyx and pubis areas: to reduce tension and/or pain in the back, pelvis, hips and legs.

DRAPING DESCRIPTIONS: Genitals and gluteal cleft below the tip of the tailbone are always draped.

• Minimal draping: Chest/breast may be uncovered at any or all times during the session, by client preference.
• Moderate draping: Chest/breasts covered most of the session, but uncovered while being specifically massaged.
• Conservative draping: Chest and breast remain covered always. I give permission for massage of:

Please choose at least one of the following options. If none are checked, we will need to go over this at the beginning of your intial appointment which may cut down on your hands on time.

If you don't make a choice, none of these areas will ever be included in your session.

Please choose at least one of the following options. If none are checked, we will need to go over this at the beginning of your intial appointment which may cut down on your hands on time.

In the event you don't make a choice I will default to Conservative draping.

I offer pregnancy massage for ALL stages of a healthy pregnancy. If you are pregnant, you will receive an additional short pregnancy form to complete upon submitting this one.

Some of the advanced clinical work I do can affect many medical conditions. Please be forthcoming with your answers so that I may provide an effective and safe session for you.

In the comment box, please indicate time period for each condition checked as follows:

C - current condition for which I'm having symptoms or being treated for

R - recent condition/symptom in the last 3 - 6 months

P - past symptom/condition (I have been told by my medical provider that I no longer have this condition)

Certain medications can affect how your body responds to massage. There may be certain forms of treatment that need to be adjusted accordingly. For your safety, please list ALL names of PRESCRIPTION MEDICATIONS AND ANY/ALL NATURAL SUPPLEMENTS AND OVER THE COUNTER REMEDIES regularly taken. 

In order to provide the safest and best possible outcome for you, it's very important for me to know of any recent or past injuries and surgeries you may have had. Approx dates, location and name of injury if you know that.

The traditional lomilomi I practice while very clinically based, is also spiritually grounded. As part of this lomilomi practice, I offer a non-religious/non-denominational PULE (blessing) at the beginning of the session for every client in the spirit of aloha.  

I aim to create a comfortable, safe, relaxing space optimum for healing.

I am more than happy to omit this from your session if that is your preferance. THIS IS OPTIONAL.

You will receive the same professional treatment and outcome regardless of your choice.

I can say this silently or out loud. 

Here's a couple of examples:

"Spirit of Peace, Spirit of Harmony, Spririt of love, bless "name of client" from the top of their head to the soles of their feet, throughout every breath and beat of their heart and in all important areas of their life. May "name of client" receive whatever they need today to restore their whole being to one of peace, balance, joy and ease. Aloha and so it is."

"Guide my hands, my head and my heart to make this the very best session possible for "name of client". May they easily access the innate healing that is for their highest good within them to bring about balance, harmony and ease for body mind and spirit. Bless "name of client" from the top of their head to the soles of their feet and in all important areas of their life... health, family, community. Aloha and so it is." 

I can customize it according to beliefs and preferred vocabulary and add in specific intentions if you wish.