Top Login

Navigation

Initial Intake Form

Please complete this form prior to your appointment and be sure to hit ‘submit’. To protect your Health Information, only provide your initials, not your full name. I will match that to your appointment day and time info, and create a paper chart that only I will touch to track our work and progress together.

Enter your initials (to maintain privacy)*
Date and Time of your upcoming appointment:*

COVID-19 SCREENING QUESTIONS: If you answer yes to any of the symptom questions, you must reschedule your appointment to after you have been symptom free for 72 hours without medical intervention or medications.

If you answer yes that you have been around someone with symptoms or diagnosed Covid-19, you must reschedule for 14 days after that exposure.

Have you had a new or worsening cough?*
Have you had a fever?*
Have you had shortness of breath?*
Have you lost sense of taste or smell?*
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*

HEALTH HISTORY AND CURRENT STATUS: do not leave blank, type n/a if not applicable to you.

Are you currently under a physician's care? (MD, DO, ND, DC, DPT, LNP, etc.) If yes, with whom and for what?*
List any surgeries, injuries or illnesses that come to mind when thinking about your current health status. *
Are you working with other Therapy providers? PT, counseling, acupuncture, other forms of bodywork, etc.? If yes, how often and please describe.*
What medications (prescriptions or over the counter), vitamins or supplements do you take? What are they for? How much and how often do you take them, and do you have side effects?*

>Please check "current" or "past" if any of the following apply to you: leave blank if not applicable.

Heart Disease
Indigestion
Osteoarthritis
Broken Bones
Athlete's Foot
Asthma
Abuse
Incontinence
HIV or AIDS
Stroke
Eating Disorder
Nicotine Use
Diabetes
Dizziness
Headaches
Migraines
Varicose Veins
Constipation
Fatigue
Cancer
Mental Health Issues
Dislocations
Allergies
Substance Abuse
High Blood Pressure
Low Blood Pressure
Easy Bruising
Numbness
Skin Conditions
Hearing Impairment
Swelling
Hypermobility
Sprains or Strains
Visual Impairment
Cold or Flu
Communicable Disease

LIFESTYLE AND HOW MAY I HELP?

What are the primary sources of stress in your life?*
Where in your body do you notice the effects of stress? What symptoms do you notice?*
What do you do for exercise? If none, what physical activities do you regularly participate in? (hobbies, etc.)*
What do you do to relax?*
What brings you in? What would you like my help the most with? (We will discuss this at your appointment in greater depth.)*

WAIVER, POLICIES AND FEES: Please read and agree to the following:

I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from Aaron Gustafson LMT, and release Transcend Bodywork LLC and Aaron Gustafson LMT from any and all liabilities in connection with COVID-19.


I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.


I understand that the purpose of this massage is to promote and maintain good health and physical condition, and that Licensed Massage Therapists may not diagnose injury or disease. Massage should not take the place of a Doctors care when care is necessary. Either you the client or the therapist may terminate the relationship should either be experiencing discomfort inappropriate to the situation, including but not limited to physical pain or sexual impropriety. I agree to abide by all office policies of Transcend Bodywork LLC and Aaron Gustafson LMT including the right to refuse service to anyone.


Fee Schedule for Billed Services

Prices are per unit, one unit = 15 minutes. One hour = 4 units. Billed Rates = $132 to $180 per hour.

CPT CODES:

97124             Massage Therapy- Therapeutic:       $45.00 (Used for Physician directed care.)

97140             Manual Therapy- Myofascial:           $45.00 (Used for Physician directed care.)

8E0KX1Z    Relaxation Massage:                           $33.00 (Used for self directed care only)

Time of Service Discount: payment at time of service eligible for 20% discount (= as low as $110/hr for 8E0KX1Z). Pre-paid promotional wellness packages of 3 sessions available at an additional $30.00 discount. Unused promotional wellness package sessions expire after 90 days from date of first package session.

Not all insurance plans cover massage – please check with your plan before requesting medical insurance billing. If your plan covers massage, please email or text pictures of the front and back of your ID card along with your birth date to aaron@transcendbodywork.com or 503-407-6046 before your first session and I’ll verify your benefits/co-pays. Auto Insurance for auto injuries happily accepted.

Payment due within 30 days of billed service. Late payments are subject to 5% monthly late fee. Clients are fully responsible for any amounts left unpaid by Insurance. FSA & HAS payments accepted as long as they’ve provided you with a debit/credit card for your account, or we can provide an invoice to help you seek reimbursement from your FSA or HSA.

Missed or canceled appointments with less than 24 hours notice still incur full session charges, due before any subsequent sessions.

Cancelled or Insufficient funds checks subject to $35.00 fee + any bank fees.

Fees and policies subject to change without notice.

By typing my initials below, I agree to the above waiver,  policies, and fees.


How will you be paying? *
TYPE YOUR INITIALS: By typing your initials, you agree they are your signature, and that you agree to all above waivers, policies and fees.*