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The information requested below will assist us in treating you safely

The information requested below will assist us in treating you safely 2026

The information requested below will assist us in treating you safely Preview on Page 1

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4.6 out of 5

21 votes

The document is a comprehensive intake form for clients seeking massage therapy, requesting personal and health information to ensure safe treatment. It includes sections for contact details, medical history, current medications, and consent for treatment. Additionally, it outlines a cancellation policy and informed consent regarding the nature of the therapy provided.

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Begin by clicking 'Get Form' to open the document in our editor.
Fill in your personal details, including NAME, EMAIL, DATE OF BIRTH, PHONE, and ADDRESS. Ensure accuracy as this information is crucial for your treatment.
Indicate your OCCUPATION and PRIMARY COMPLAINT. This helps the therapist understand your background and specific needs.
Select how you heard about the service from the provided options. This feedback is valuable for our outreach efforts.
Complete the sections regarding your HEALTH HISTORY and EMERGENCY CONTACT. Be thorough to ensure safety during treatment.
Review the list of conditions and check any that apply to you. This section is vital for tailoring your therapy.
Finally, read through the CANCELLATION POLICY and INFORMED CONSENT sections carefully before signing and dating at the bottom of the form.

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Versions	Form popularity	Fillable & printable
2017	4.6 Satisfied (21 Votes)

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What is the assist assessment?

ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) The World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is a questionnaire that screens for all levels of problem or risky substance use in adults.

What is assist assessment?

ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) On this page. The World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is a questionnaire that screens for all levels of problem or risky substance use in adults.

What questions are asked in a drug and alcohol assessment?

An alcohol abuse evaluation or any substance abuse assessment will ask you questions such as: How much alcohol do you drink? How often do you drink? What kind of alcohol do you drink? When was your last drink? What were the circumstances surrounding your last drink? Do you ever feel guilty or ashamed after drinking?

What other factors in your life help protect you from using drugs?

Individual-level protective factors might include positive self-image, self-control, or social competence.

How many items are on the assist questionnaire?

The revised version of the ASSIST (V3. 0) consists of eight questions or items, covering tobacco, alcohol, can- nabis, , amphetamine-type stimulants (including ecstasy), inhalants, sedatives, hallucinogens, opioids and other drugs, that can be answered by most patients in around 10 minutes.

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