Intake Form (WA.ver. 3)

The information request below will assist us in treating you safely. Feel free to ask any questions about the information being requested. Please note that all information provided below will be kept confidential unless allowed or required by law. Your written permission will be required to release any information.

Purpose of Treatment

I understand that massage therapy provided by Yaima Massage & Movement is performed for therapeutic purposes only, including pain relief, injury recovery, postural support, movement improvement, and functional performance.

Certain conditions may require treatment of sensitive areas such as the chest/breast region or gluteal muscles when clinically appropriate.

1. Chest & Breast Massage Consent (WAC 246-830-555)

Legal Note: Under WAC 246-830-005, massage of the chest, shoulder, intercostal, pectoral, or axillary (armpit) muscles does not constitute breast tissue massage. However, specific, deliberate manipulation of breast tissue requires explicit prior written and verbal consent.

Therapeutic Rationale / Reason for Treatment

Post-surgical recovery / Scar tissue release
Lymphatic drainage
Pectoral / Chest muscle strain or tightness
Postural correction / Rounded shoulders relief
Pain management / Mastalgia / Tenderness relief

2. Gluteus, Sacral, and Coccyx Massage Consent (WAC 246-830-557 & 560)

Therapeutic Rationale / Reason for Treatment

Sciatica / Piriformis syndrome / Nerve entrapment
Low back, hip, or pelvic pain/dysfunction
Gluteal muscle strain, tightness, or trigger points
Sacroiliac (SI) joint dysfunction
Tailbone / Coccyx pain (Coccydynia)

Consent for Therapeutic Breast/Chest Treatment (Select authorized area):

Upper Chest & Surrounding Muscles ONLY: Pectorals, intercostals, axillary (armpit), clavicular regions (Not breast tissue).

Breast Tissue Massage: Specific, deliberate massage of the breast tissue.

Nipple & Areola Inclusion: Specific massage involving the nipple or areola.

Treatment Area Selection (Select authorized area):

Gluteal Region: Massage of the gluteus maximus, medius, and minimus muscles.

Sacrum: Massage along the sacral bone and SI joint borders.

Coccyx Area: External massage near/around the coccyx (tailbone).

Gluteal Cleft Area: Work along the muscle attachments adjacent to the gluteal cleft fold (perineum and anus remain fully draped/covered at all times).

Draping & Coverage Options (Select ONE):

Standard Draping: Drapes are temporarily moved/adjusted only to work on authorized specific body parts and re-secured immediately afterward.

Upper Torso Undraped Option: I choose to have my upper torso undraped during the entire massage session for therapeutic comfort (WAC 246-830-560(3)).

Client is Under 18 Years of Age (WAC 246-830-555(1)(a) & (3)(b)):

Parent/Legal Guardian written consent is required for clients under 18 years of age.

Clinical Photos & Documentation （Rquired）

Clinical photos and/or videos (such as posture assessment, movement screening, or self-care exercise demonstrations) may be taken as part of your treatment. These images are used to document your condition, support clinical assessment, guide treatment planning, and track progress over time. These materials become part of your confidential clinical record and are handled in accordance with applicable privacy laws.

Optional Use for Education, Marketing, or Public Materials

Non-identifiable photos or videos may be helpful for professional education, workshops, case studies, website content, or social media. Identifiable images will never be used without additional, specific written consent.