In the March 5th edition of LegitMassage.com we highlighted several things to know before your Massage session and briefly touched on the topic of the Client Intake Form. Today, we discuss in more depth the importance of the Intake Form and what information it should contain in order to maximize the effectiveness of the treatment.
First, why is the Intake Form important?
- The Intake provides any necessary information that the therapist may need to know to effectively assess an issue and address with a personalized treatment plan.
- Because different issues and ailments vary from person to person, treatments will vary as well. What may be an effective treatment plan for one person may not be as effective for another. The Intake Form is the blue print of how to build a healthier structure.
- The Intake Form provides information to the therapist as to what focus areas to concentrate on. It allows you to take an active role in your own treatment plan and develop a priority of what needs focus.
- The intake gives the therapist an idea of any contraindications to avoid during the treatment. Many times the intake will reveal any allergies that you may have as well as any accidents or injuries you have suffered in the past that the therapist needs to know about. Like that dislocated shoulder you suffered in 6th grade!
Next, what information does the Intake Form need to contain?
- At the very least, the intake should ask for a brief review of your medical history and include any current medications as that is important for the therapist to know. This includes any accidents, injuries, surgeries, or other medical conditions the therapist needs to know about.
- Any current issues or ailments should be addressed in the Intake Form. This gives the therapist an idea of what kind of treatment you desire. If you list sore Iliotibial Bands or ITBs on your Intake Form, the therapist will know that you are looking for more than a stress relief/relaxation massage and instead may benefit from deeper tissue work to the hip flexors as well as knee extensors and antagonist knee flexors, etc.
- Your contact data should be present on the form. This includes a contact phone number and email address. Home address, other phone numbers, and date of birth may be optional information as well.
Some Intake Forms include body maps and assessment charts. This enables the therapist to track any trigger points, ranges of motion, chart strengths of muscles and note any tissue characteristics. Maps and charts further increase the effectiveness of the treatment plan. I have sometimes seen longer Intake Forms that provide a detailed check the box list of many different and various pathologies. Others may include an area for the patient to chime in on their own preferences as to what kind of massage they like and any areas to key in on or avoid. Some states require that you sign a confidentiality disclosure as part of the Intake Form. If insurance is accepted, a HIPPA agreement is mandatory and is often filled out at the beginning of treatment. A HIPPA or Health Insurance Portability and Accountability Act of 1996 basically ensure confidentiality and limits who has the right to see healthcare information.
Licensed Massage Therapists use the initial interview as the beginning point to a successful treatment plan. The Intake Form is the first bit of information that we learn about you. As the therapeutic relationship develops, we file the form of initial information and build upon it with a subsequent form called a SOAP note to track your progress. A SOAP form contains information that you tell us, information we observe, anything we assess during palpation or treatment, and lists what we did during our session. Hence SOAP, Subjective, Objective, Assessment, Plan. Intake Forms and SOAPs vary as do treatments. A commonality is the process and keystone in helping to render a healthier you.
Kip Yates, LMT was trained at the Swedish Institute in New York City and is New York State and Texas State licensed. He is owner and operator of Massage Refresh in New York City where he provides Swedish wellness and recuperative Deep Tissue massage that encompasses myofascial release and trigger point therapy. Kip lives in Brooklyn with his wife and three children and also practices at Physiofitness Physical Therapy in Soho.