Massage Intake Form Please complete and submit this form prior to your first appointment. Any field marked with an asterisk ('*') is required. "*" indicates required fields 1Personal Information2Wellness3Referrals4Disclosures5Releases Welcome! We are honored to have the opportunity to work with you. We want to make your session as pleasant and as comfortable as possible. Please provide the following information to help us understand your needs and inform our treatment plan for you. If at any time during the treatment you have questions, please let us know."Personal InformationFull Legal Name of the person being seen* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Sex* Male Female Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address* Mobile Phone*Work PhoneHome PhoneOccupation* Emergency Contact* Phone*Relationship To You* How did you hear about us?* WellnessOn a scale from 1 - 10 with 10 being 'excellent', how would you rate your current health in each of these areas:Nutritionally*Select10 (Excellent)987654321 (Terrible)Emotionally*Select10 (Excellent)987654321 (Terrible)Spiritually*Select10 (Excellent)987654321 (Terrible)Relationally*Select10 (Excellent)987654321 (Terrible)Physically*Select10 (Excellent)987654321 (Terrible)Financially*Select10 (Excellent)987654321 (Terrible)Please check any condition listed below that applies to you: phlebitis osteoporosis headaches/migraines diabetes back/neck problems TMJ tennis elbow contagious skin condition easy bruising recent fracture artificial joint current fever allergies/sensitivity high or low blood pressure varicose veins joint disorders / tendonitis deep vein thrombosis/blood clots epilepsy cancer decreased sensation fibromyalgia carpal tunnel syndrome pregnant open sores or wounds recent accident or injury recent surgery sprains / strains swollen glands heart condition circulatory disorder atherosclerosis rheumatoid arthritis/osteoarthritis How many months pregnant are you?Please enter a number from 0 to 16.Please explain any condition(s) you have marked:What other therapies are you currently receiving? Physical Therapy Chiropractic Adjustment Acupuncture Treatments Other Please explain your other therapy:Please list any surgeries, fractures, bones breaks, sprains or unusual unexplained pain:IssueDateTreatment / Outcome Add RemoveWhat is your current level of pain or discomfort?*1 (Slight)2 (Minor)3 (Moderate)4 (Substantial)5 (Intense)Select the areas where you are experiencing pain or stress accumulation: Scalp Face Left Neck Left Upper Back Left Lower Back Left Shoulder Left Chest Left Arm / Elbow Left Hand / Wrist Left Hip / Waist Left Buttock Left Thigh / Knee Left Calf Left Foot / Ankle Right Neck Right Upper Back Right Lower Back Right Shoulder Right Chest Right Arm / Elbow Right Hand / Wrist Right Hip / Waist Right Buttock Right Thigh / Knee Right Calf Right Foot / Ankle Referral ServicesTotal Health Guidance networks with many trusted businesses in the community. We do not have any financial ties to these businesses, but would be happy to provide you with information about them. Other than what you are coming for, please select which other service(s) you would like more information about:hich service(s) you are interested in receiving information about: A/C & Heating (sales, service) Acupuncture Attorney - Business Law Attorney - Criminal Defense, Traffic Tickets Attorney - Family (divorce, custody, child support, etc.) Attorney - Immigration Auto Dealer & Repair Banker (personal, business) Business Consulting Business Marketing Caterer Chiropractor Counselor/Life Coach (individual, marriage, family, career) (Offered at Total Health Guidance) CPA (tax returns, audit representation, business start-up) Digital Marketing (SEO, website design, video, social media) Financial Planner (investments, IRA, 401k) Firearms Instructor Handyman / Lawn Maintenance Health Coaching (Offered at Total Health Guidance) Health Insurance (individual, group) Home Care Assistance Insurance (auto, home, business) Interior Design Legal Shield / Identity Theft Life Insurance Massage Therapy (Offered at Total Health Guidance) Merchant Services Movers (residential, commercial) Nutritional Counselor (Offered at Total Health Guidance) Office Supplies Office Furniture Payroll Services Photographer / Portrait Design Printing / Promotional Products Residential Cleaning Service Residential Mortgage (purchase, re-fi, construction, reverse) Residential or Commercial Estate Roofing Travel Agent Wedding / Event Planner Disclosures and ConsentFINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT*Total Health Guidance, LLC - Disclosure Statement Thank you for deciding to seek out treatment at Total Health Guidance. We have listed below our various policies for your information. Please read through these, ask any questions, and sign at the bottom. You may call (321) 332-6984 regarding any questions you may have. All of the therapists at THG are licensed through the State of Florida and/or the Florida Association of Christian Counselors & Therapists. Total Health Guidance is not a 24 hour treatment center. In an emergency, please call 911. We have been trained in a variety of counseling techniques. We will work with you to verify which techniques might be most effective for your particular needs. You may, at any time, seek a second opinion from another therapist and/or you may terminate our services at any time without penalty. SESSIONS: Sessions are typically scheduled for 50 minutes at a frequency to be determined by the counselor and client. PAYMENT POLICY: We see clients on a fee-for-service basis only. The client/parent is responsible for payment in full at the time of each session. Additional time options and cost can be established with the therapist. Our policy is for each person to pay for services at the time they are rendered. Any other arrangements must be made in advance. A $25 administrative fee will be charged on all checks that are returned for non-sufficient funds. Payments can be made by cash, check or credit card. Charges for testing services are an additional fee. INSURANCE: If you desire to use in-network benefits, confirmation of coverage must be completed prior to your appointment. We are not in-network with many insurance carriers. Until coverage is confirmed, you will be required to pay in-full for all appointments. If you desire to use out-of-network benefits, please direct questions about reimbursement amounts and timeliness to your insurance company. We can provide you with a receipt for the counseling service that may be used to submit for reimbursements if you choose. We do not complete any insurance paperwork for out-of-network benefits. If you elect to use your health insurance plan to assist in the payment of treatment then you understand that your insurance carrier and the National Information Center will have access to your diagnosis code and other pertinent data needed for processing. CANCELLATIONS: We understand that it may, at times, be necessary to cancel an appointment. We require that changes / cancellations be made 24 hours in advance. Any changes, cancellations, or missed appointments within the 24 hour period will result in a $40 cancellation charge. CONFIDENTIALITY: The confidentiality of the services provided by us is protected by law. Unless you grant us permission to do so in writing, we will neither inform anyone that you are a client, nor will we disclose the content of any session. The only circumstances under such professional confidentiality may be broken is if one or more of the following conditions apply: If you pose a serious physical danger to yourself or to another person. If you disclose that you or another person has physically or sexually abused or molested a child or an incompetent / disabled person. If you disclose that a child, an incompetent / disabled person is suffering because of neglect. If such abuse or neglect is disclosed, we are mandated by Florida law to report such information to an appropriate state agency. I have read the preceding information and agree to it. I authorize treatment of the person named below and agree to pay all fees.HIPAA NOTICE OF PRIVACY RIGHTS*Notice of Privacy Practices Please keep for your records This Notice describes the confidentiality of your medical information, and the limited ways that medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. We care about our patients’ privacy and strive to protect the confidentiality of your medical information. Federal legislation requires that we issue this official notice of our privacy practices. You have the right to confidentiality of your medical information, and we are required by law to maintain the privacy of that protected information. We are required to abide by the terms of this Notice of Privacy Practices, and to provide you with notice of our legal duties and privacy practices with respect to protected health information you provide to us. If you have any questions about this Notice, please contact the privacy officer, John Stiteler, at this office. Who Will Follow This Notice? Your counselor and all business associates working with Total Health Guidance (THG), who share your personal health information, such as insurance or managed care companies, must follow these same privacy practices. When personal health information is shared, only the minimum necessary information needed to accomplish this task will be disclosed. Uses and Disclosures of Protected Health Information Requiring Your Written Authorization In most cases, THG may not use or disclose information in your health records that could identify you (Protected Health Information) without your written authorization except for the reasons described below. If you give us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will thereafter no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care we have provided you. How We May Use and Disclose Medical Information Without Your Authorization There are limited circumstances where an authorization is not needed for disclosure of personal information. Most, but not every possible use or disclosure category are listed below. This Notice applies primarily to information contained in your medical and billing records. More detailed and personal information contained in provider’s "psychotherapy notes" are kept separately and are given an even greater degree of privacy and protection than the personal health information contained in your medical and billing records. As such, these would require written authorization even for the standard disclosure exceptions listed below. For Payment.We may use and disclose medical information about you without specific authorization so that the treatment and services you receive from us may be billed and payment may be collected from you, an insurance company or a third party. Example: We may release your protected health information, such as your name, address, office visit date, and codes identifying your diagnosis and treatment to your insurance company for payment. In most cases, insurance companies may review your medical record to verify services were rendered and were medically necessary in accordance with your contract. Other Uses or Disclosures That Can Be Made Without Consent or Authorization.We may, at our discretion, contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you without your specific release. • To avert a serious threat to health or safety • Child abuse or neglect • Abuse of elderly or incapacitated adults • Court ordered evaluations or information • Health oversight activities, such as for federal enforcement of these privacy practices Your Rights Regarding Complaints Concerning Use or Disclosure of Your Health Information.If you believe your privacy rights have been violated, you may file a complaint with THG’s Privacy Officer or with the Secretary of the Department of Health and Human Services, whose address will be provided to you by the Privacy Officer, at your request. All complaints must be submitted in writing. Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, THG is not required to automatically agree to a restriction you request if the provider is otherwise obligated to release that information. Your request must be in writing and specifically state what information you wish to limit. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations. You have the right to request and receive confidential communications of private health information by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing a provider at this practice. Upon your request, this practice will send your bills to another address, or arrange to call you only at work instead of home.) Right to Inspect and Copy. You have the right to inspect or obtain a copy (or both) of private health information in this practice’s mental health and billing records used to make decisions about you for as long as the information is maintained in the records. On your request, your provider or the privacy officer will discuss with you the details of the request process. Right to Amend. You have the right to request an amendment of private health information as it is maintained in the record. Your provider may deny your request if, in his or her opinion, it would compromise the accuracy of your medical information. Right to an Accounting. You generally have the right to receive an accounting of any disclosures of medical information. On your request, your provider or the privacy officer will discuss with you the details of the accounting process. Right to a Paper Copy. You have the right to obtain a paper copy of this notice from your provider or the practice upon request, even if you have agreed to receive the notice electronically. Changes to This Notice. We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. I have received a copy of our HIPAA Notice of Privacy Rights.Please type your full name below to confirm the above acknowledgements and consent:*Electronic signature Release of Information AuthorizationUse this form to authorize Total Health Guidance to share your information with others as may become necessary. Completion of this form is required for all clients.Please provide the names and contact information for the individuals with whom we may share your information:HiddenRecipient 1{Eval. Contact Name:45} (my {Eval. Contact Relation:56})HiddenRecipient 1{Insurance Provider:60} (my insurance provider)HiddenRecipient 1{Spouse / Partner Name:25} (my spouse/partner)Additional Recipient 1 First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information Types Attendance Diagnosis Records Treatment Plan Authorization I authorize the release of information from Total Health Guidance to the individual listed above and according to my selection(s) above.Additional Recipient 2 First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information Types Attendance Diagnosis Records Treatment Plan Authorization I authorize the release of information from Total Health Guidance to the individual listed above and according to my selection(s) above.Additional Recipient 3 First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information Types Attendance Diagnosis Records Treatment Plan Authorization I authorize the release of information from Total Health Guidance to the individual listed above and according to my selection(s) above.Please type your full name below to confirm the above selections and consent:*Electronic signature CommentsThis field is for validation purposes and should be left unchanged.