Marion Jenkins Therapies Dibden Purlieu - Organic treatments to make you feel amazing

1

Client Details

Your personal and contact information

Full Name *

Date of Birth *

Address

Telephone *

Email Address

Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact Telephone

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2

Health Information

Please tick all that apply — this helps Marion tailor your treatment safely

Tick any conditions you currently have or have ever had. You can select as many as apply.

Do you currently have, or have you ever had, any of the following?

Other condition (please specify)

Medication & Allergies

Are you currently taking any medication?

Do you have any allergies or sensitivities?

Pregnancy

Are you pregnant?

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3

ASMR Experience & Preferences

Help Marion understand your experience and what you enjoy

ASMR Experience

Have you experienced ASMR sensations before?

Frequently Occasionally Rarely Never

Preferred Triggers

What types of ASMR triggers do you enjoy? (tick all that apply)

Other triggers you enjoy

Are there any triggers you dislike or would prefer to avoid?

Atmosphere Preferences

During your treatment, do you prefer:

Complete silence Minimal conversation Gentle guidance

Would you like background music?

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4

Touch Consent & Comfort

Tell Marion where you are and are not comfortable being touched

Your comfort and boundaries are Marion's priority. Please be as specific as you need to be — nothing you say here will affect the quality of care you receive.

Areas comfortable to include

Please tick all areas you are happy for Marion to include in your treatment:

Areas you would prefer NOT to be touched

Sensitivities & Comfort

Do you have any areas that are particularly sensitive to touch?

Have you ever experienced discomfort, anxiety, or distress during massage or close-contact treatments?

If yes, please explain

Is there anything else that would help Marion make your treatment feel safe, comfortable and relaxing?

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Goals, Consent & Signature

Your treatment goals and formal consent

What would you most like to achieve?

Other goals

Important Information

ASMR massage is a relaxation treatment designed to encourage calmness, comfort and wellbeing through gentle touch and sensory-focused techniques.

ASMR sensations vary from person to person and cannot be guaranteed.

This treatment is entirely non-sexual and professional in nature.

You may request modifications or stop the treatment at any time.

Consent

Client Signature

Please sign in the box below using your mouse, finger or stylus.

Sign here…

Date *

🔒 Your privacy: Clicking Generate PDF creates your PDF within your browser. Your basic contact details (name, date of birth, phone and email) are saved securely with Marion Jenkins Therapies. Your health information stays in the PDF only and is never stored on any server.

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ASMR Massage Consultation & Consent Form

Marion Jenkins Therapies

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