Gaja Bohème
Holistic Wellness
Cater to Your Higher Self
✦ About 3 minutes · Answer what feels true
About You1 of 5
01 — Getting started
About You
Your basic details so we can hold space for you with full intention.
02 — Medical history
Health & Safety
Everything here is strictly confidential and shapes how we work with your body.
Are you currently under the care of a physician or mental health provider?
Have you received professional massage or energy work before?
03 — Safety screening
Contraindications & Conditions
Select everything that applies. This tells us which modalities are safe for your body today.
Cardiovascular / Circulatory
Respiratory
Neurological / Nervous System
Musculoskeletal
Reproductive / Hormonal
Skin & Tissue
Other
Sensory & Environmental Sensitivities
04 — Right now
How You Feel Today
This tells us how to pace and calibrate your session. No right answers.
Pain level5
None at allSevere
Stress level5
Completely calmOverwhelmed
Energy level5
Completely depletedFully energized
Where do you hold tension most? (select all that apply)
When stressed or overwhelmed, you tend to…
What is your intention for this session?
05 — Final step
Consent & Signature
Please read and confirm each statement, then sign below.

I understand that massage therapy and energy work are not substitutes for medical or psychological care.

I understand that I may experience physical, emotional, or energetic responses during and after a session. I agree to communicate any discomfort immediately.

I understand that consent is ongoing. I may pause or stop the session at any time without explanation.

I understand that sexual behavior, advances, or inappropriate comments are not tolerated and will result in the immediate termination of the session without refund.

I acknowledge that all information I share is held in strict confidence within legal and ethical limits.

I confirm that all information I have provided is accurate to the best of my knowledge.

Signature *

Gaja Bohème Holistic Wellness

Confidential · All rights reserved