Massage Therapy Program

Name:_______________________________________ Date:_____________________________
If you are a female, are you pregnant? ________yes ________no

Effective September 3, 2003

Massage Therapy Program Clinical Procedures

West Bank Campus

POLICY STATEMENT

Delgado Community College’s Massage Therapy Program offers academic and clinical

education in the practice of therapeutic massage. Upon successful completion, students are eligible to

take the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) Exam and

the State Licensure Exam. The program includes three clinical courses—MSTH 151, Massage Therapy

Clincial I, MSTH 152, Massage Therapy Clinical II, and MSTH 153, Massage Therapy III.

Massage Therapy Clinicals I, II, and III are supervised clinical education for the students and

they provide opportunity for clinical training with members of the public. These clinical courses are

operated in accordance with Louisiana Revised Statute Title 37, Chapter 57,

Massage Therapists and

Establishments,

and the Louisiana Board of Massage Therapy, Title 46,

Professional and Occupational

Standards.

Specific information and procedures are outlined further in this document.

PROCEDURES AND SPECIFIC INFORMATION

Definitions

In accordance with Louisiana Revised Statute Title 37:3552, the following definitions apply:

A. "Massage therapist" means an individual who practices or administers massage therapy to

a patron of either gender for compensation. The term shall include a therapeutic massage

practitioner, massage technician, masseur, masseuse, or any derivation of those titles.

B. “Massage therapy" means the manipulation of soft tissue for the purpose of maintaining

good health and establishing and maintaining good physical condition. The term shall

include effleurage (stroking), petrissage (kneading), tapotement (percussion),

compression, vibration, friction, (active/passive range of motion), Shiatsu, and

acupressure, either by hand, forearm, elbow, foot, or with mechanical appliances for the

purpose of body massage. Massage therapy may include the use of lubricants such as

salts, powders, liquids, creams, (with the exception of prescriptive or medicinal creams),

heat lamps, whirlpool, hot and cold pack, salt glow, or steam cabinet baths. It shall not

include electrotherapy, laser therapy, microwave, colonic therapy, injection therapy, or

manipulation of the joints. Equivalent terms for massage therapy are massage,

therapeutic massage, massage technology, Shiatsu, body work, or any derivation of those

terms.

C. “Therapy" and "therapeutic" shall not include diagnosis, the treatment of illness or

disease, or any service or procedure for which a license to practice medicine,

chiropractic, physical therapy, or podiatry is required by law.

D. "Massage therapy instructor" means an individual who is licensed as a massage therapist,

who possesses credentials satisfactory to the State of Louisiana Board of Massage

Therapy and who meets criteria established by the Board.

E. “Student massage therapist” means an individual who is enrolled in the Delgado

Community College Massage Therapy Program Clinical I, II, or III.

F. “Client” means an individual who is receiving massage therapy from a Delgado massage

therapy instructor or student.

G. “Drape” means towels, gowns, or sheets used to cover clients while massage therapy is

being delivered.

Code of Ethics

Students and instructors involved in the clinical instruction of the Delgado Massage

Therapy Program operate in accordance with the following established “Code of Ethics” of the

Louisiana Board of Massage Therapy. Students and instructors are expected to:

1. Represent their qualifications honestly, including education and professional

affiliations, and provide only those services which they are qualified to perform.

2. Accurately inform clients, other health care practitioners, and the public of the scope and

limitations of their discipline.

3. Acknowledge the limitations of and contraindications for massage and bodywork and

refer clients to appropriate health professionals.

4. Provide therapy only where there is reasonable expectation that it will be advantageous to

the clients.

5. Consistently maintain and improve professional knowledge and competence, striving for

professional excellence through regular assessment of personal and professional strengths

and weaknesses and through continued education training.

6. Conduct their business and professional activities with honesty and integrity, and respect

the inherent worth of all persons.

7. Refuse to discriminate against clients or other ethical health professionals.

8. Safeguard the confidentiality of all client information, unless disclosure is required by

law or court order, or is deemed absolutely necessary for the protection of the public.

9. Respect the client's right to therapy with informed and voluntary consent.

10. Respect the client's right to refuse, modify, or terminate therapy regardless of prior

consent given.

11. Exercise the right to refuse to treat any person or part of the body for just and reasonable

cause.

12. Refrain, under all circumstances, from initiating or engaging in any romantic or sexual

conduct, sexual activities, or sexualizing behavior involving a client, even if the client

attempts to sexualize the relationship.

13. Respect the client's boundaries with regard to privacy, disclosure, exposure, emotional

expression, beliefs, and the client's reasonable expectations of professional behavior.

Practitioners will respect the client’s autonomy.

Professional and Occupational Standards

The clinical component of the Delgado Massage Therapy Program operates in

accordance with the

Professional and Occupational Standards established by the Louisiana Board

of Massage Therapy. Specifically, the following standards and requirements are followed.

Safety and Sanitary Requirements

The Delgado Massage Therapy Program clinic is maintained in a safe and sanitary

manner and has adopted the

Safety and Sanitary Requirements,

Chapter 25:2501A of Title 46,

Board of Massage Therapy. As follows, the program will:

1. Comply with all state and local building fire and safety code requirements.

2. Provide for safe and unobstructed human passage in the public areas of the

premises, removal of garbage and refuse and safe storage or removal of

flammable materials;

3. Maintain on the premises a fire extinguisher in good working condition;

4. Exterminate all vermin, insects, termites, and rodents on the premises;

5. Maintain all equipment used to perform massage services on the premises in a

safe and sanitary condition;

6. Launder, before reuse, all materials furnished for the personal use of the client,

such as towels and linens;

7. Provide adequate toilet and lavatory facilities. To be adequate, such facilities

must have at least one (1) toilet and one (1) sink with running water. Such

facilities will be equipped with toilet tissue, soap dispenser, with soap or other

hand cleaning materials, sanitary towels or other hand-drying device such as a

wall-mounted electric hand dryer, and waste receptacle. Such facilities and all of

the foregoing fixtures and components will be kept clean, in good repair, well-

lighted, and adequately ventilated to remove objectionable odors;

8. Adequately maintain shower facilities on the premises if equipped with a

whirlpool bath, sauna, steam cabinet and/or steam room;

9. Maintain current liability insurance coverage. The original or a copy of the policy

will be available on the premises of the facility;

10. Maintain toilet facilities in

a common area of the facility; and

11. Maintain lavatories for hand cleansing and/or chemical germicides designed to

disinfect and cleanse hands without the

use of a lavatory in the treatment room

itself or within twenty (20) feet of the treatment area.

Draping

The Delgado Massage Therapy Program clinic uses draping Procedures as specified in

Draping,

Chapter 25:2501B of Title 46, Board of Massage Therapy as follows.

(1) The facility will maintain a sufficient supply of clean drapes for the purpose of

draping each client during massage;

(2) Before beginning a massage, each massage therapist will have explained expected

draping techniques and provided the client with a clean drape for that purpose;

and

(3) In the case of a male client, buttocks and genitalia must be covered;

and, in the case of a female client, breasts, buttocks, and genitalia must be

covered.

Prohibition of Sexual Activity

The Delgado Massage Therapy Program clinic prohibits sexual activity as specified in

Prohibition of Sexual Activity,

Chapter 29:3101 of Title 46, Board of Massage Therapy as

follows.

(1) All sexual activity by any person or persons in the facility is prohibited;

(2) No instructor, student or employee of the Delgado Massage Therapy Program will

engage in or permit any person or persons to engage in sexual activity in the

facility or to use the facility to make arrangements to engage in sexual activity in

any other place;

(3) No licensed massage therapist or student massage therapist will use the therapist-

client relationship to engage in sexual activity with any client; and

(4) “Sexual activity” means any direct or indirect contact or connection by any

person, or between persons, which is intended to erotically stimulate either or

both persons or which is likely to cause such stimulation (this includes sexual

intercourse, fellatio, cunnilingus, masturbation, or anal intercourse). For purposes

of this policy, “masturbation” means the manipulation of any body tissue with the

intent to cause sexual arousal. Sexual activity can involve the use of any device

or object and is not dependent on whether penetration, orgasm, or ejaculation

occurs.

Student Massage Therapist Eligibility

Delgado Community College’s student massage therapists must adhere to the

following requirements in order to participate in the massage therapy clinical courses:

(1) In order enroll into MSTH 151 Massage Therapy Clinical I, several prerequisites must be

met. They include BIOL 251, 253; and the student and must be eligible to take ENGL

101 and MATH 096.

(2) If a student is enrolled in MSTH 151, he/she must also be enrolled in the following

courses:

MSTH 101 (Introduction to Massage Therapy) (30 instructional hours)

MSTH 102 (Fundamentals of Swedish Massage) (60 instructional hours)

MSTH 103 (Muscle/Skeletal Anatomy and Palpation Skills) (60 instructional hours)

BIOL 252, 254 (90 instructional hours)

(3) Once a student has completed MSTH 102 and MSTH 103 he/she may take MSTH 151 at

any time with any other courses.

(4) Students must receive a C or better in MSTH 151, in order to take MSTH 152 Massage

Therapy Clinical II.

(5) Students must receive a C or better in MSTH 152, in order to take MSTH 153 Massage

Therapy Clinical III.

(6) MSTH 151 Clinical I (45 instructional hours) Swedish techniques will be incorporated in

each individual massage therapist’s routine. Each massage will last 50-60 minutes.

(7) MSTH 152 Clinical II (45 instructional hours) will include Swedish, sports,

neuromuscular and deep tissue techniques. These techniques will be incorporated in each

therapist’s routine. Each massage will last 50-60 minutes.

(8) MSTH 153 Clinical III (45 instructional hours) Students will work with different

modalities and different populations of people. Students may also work with an agency

from the community. Each massage will last 50-60 minutes.

Massage Therapy Program Clinic Operation

In order for students to receive and incorporate valuable information during their clinical

experience, the massage therapy program provides massages to the public. The following

procedures and guidelines are followed:

(1) The operation of the Massage Therapy Program clinic, located in Building 2, Room 139,

on the West Bank Campus, is supervised by the Massage Therapy Program Director, with

the assistance of Massage Therapy Program instructors.

(2) All clinical classes are held in the Massage Therapy Program clinic from 6 p.m. to

10 p.m. The facility is equipped with curtained massage stations separated by curtains to

provide an opportunity for instructor supervision while maintaining the client’s privacy.

(3) In Clinical I and II the students will perform two massages on clinic nights. Clinical III

students will perform three massages on clinic nights.

(4) A fee of $15.00 must be paid by the client at the West Bank Campus Bursar’s office prior

to the massage. For cases in which a scheduled client cancels an appointment, a

volunteer client will

be scheduled at no cost.

(5) A Waiver Form/ Release of Liability must be filled out by all clients prior to the massage.

(6) Client History Forms must be completed by the client; the student massage therapist

discusses the form with client prior to the massage. These forms must be updated

by the client and reviewed by the student massage therapist and client upon each return

visit.

(7) Student massage therapists must adhere to the expectations listed in

Student Massage

Therapist Expectations for MSTH 151, 152, and 153

(Attachment A). Instructors and

student massage therapists must also follow the clinical protocol as outlined in

Massage Therapy Clinical Protocol for MSTH 151, 152, and 153

(Attachment B).

Massage Procedures in the Clinic

(1) Student therapist massages will last from 50-60 minutes and include work on the head,

face, neck, shoulders, arms, back, abdomen, upper chest, legs, hands and feet.

(2) The student massage therapist may use several different techniques throughout the

massage including effleurage (smooth gliding), kneading, rocking movement, movement

re-education, range-of-motion, and application of pressure to specific points on the body.

(3) In Clinical II and III, the student massage therapist may be able to customize a massage

to meet the client’s needs and requests taken from the client intake form.

(4) Most massage techniques are usually preformed with the client unclothed, to his or her

level of comfort, on a comfortable massage table. In the case of a male client, buttocks

and genitalia must be covered; and, in the case of a female client, breasts, buttocks, and

genitalia must be covered.

(5) The client will always be properly draped with a sheet, and only the area being massaged

will be exposed.

(6) The student massage therapist may use oils, lotions, and heat during the massage.

(7) Client confidentiality regarding information on the client intake form and pertaining

to conversations with the client will be adhered to at all times.

(8) Respect for the client’s boundaries with regard to privacy, disclosure, exposure,

emotional expression and beliefs will be adhered to at all times.

(9) The student massage therapist may only use those techniques practiced in class and

within the scope of practice of a student massage therapist at that time.

(10) All clinics will be monitored by the instructor teaching the course and/or the program

director; a minimum of three (3) visits by the instructor/director during a massage by a

student massage therapist is required.

Client Procedures

(1) Clients must call 361-6417 to schedule an appointment.

(2) Clients will be required to pay $15 for the scheduled massage at the Bursar’s Office

prior to the appointment. A paid receipt is required for a massage, except in cases

of volunteer appointments due to cancellations.

(3) Clients enter the intake area of the Delgado Massage Therapy clinic.

(4) Clients will be seated in the waiting area and asked to complete a “

Client Intake Form

(Attachment C) and a

Release of Liability/Express Assumption of Risk

(Attachment D).

(5) Clients will be interviewed by the student massage therapist using the client intake

form. Student massage therapists are responsible for client intake forms, “SOAP” Notes

(

ubjective Evaluation/

bjective Evaluation/

pplication/

lan & Progress),

(Attachment E) and filing all client folders.

(6) The student massage therapist will lead the client to a cubicle for a massage.

(7) The student massage therapist will inform the client about the massage and instruct the

client to undress to his or her level of comfort. The therapist will instruct the client

that he or she must be covered at all times except for the body part being massaged. In

the case of a male client, buttocks and genitalia must be covered; and, in the case of a

female client, breasts, buttocks, and genitalia must be covered.

(8) The client reserves the right to exclude a body part from being massaged. In particular,

the student massage therapist

will ask the client if he or she wants a face and abdomen

massage.

(9) The massage will last from 50-60 minutes and generally will include work on the head,

neck, shoulders, arms, back, upper chest, legs, hands, feet, and face and abdomen (as

desired by the client).

(10) When the student massage therapist is finished he or she will inform the client and step

out of the cubicle. The client will be informed to take his or her time off the table, get

dressed when they are ready, and to meet the student massage therapist in the intake area.

(11) The student massage therapist will bring water to the client and encourage the client

to consume plenty of water to help flush out the body.

(12) The student massage therapist will ask the client to complete a

Student Massage

Therapist Evaluation Form

(Attachment F) and submit it to the staff assigned at the

facility prior to his/her departure.

Attachment A

Student Massage Therapist Expectations

for MSTH 151, 152, 153

PROFESSIONALISM

The student will demonstrate a professional attitude at all times. Students will demonstrate

professional ethics while providing services in a clinical setting.

Specifically:

I. Attitude / Conduct

a) Arrive 30 minutes before the first appointment is scheduled to begin.

b) Have appropriate linens and supplies for your sessions. Prepare massage area. Remember

to adjust table height.

c) Be ready for your client 15 minutes before scheduled appointment.

d) Use restroom, wash hands, calm yourself, stretch/breathe, drink water before each

session.

II. Appearance

a) All students are to be in proper uniform: black pants, white or black polo shirt with

Delgado logo, sneakers or Birkenstocks with socks.

b) Hair neat and pulled back; nails neat and trimmed and all jewelry removed.

c) Be aware of your breath and body odors. Always use breath mints.

d) Massage area and drapes are neat and clean.

III. Client Rapport / Therapeutic Communications Procedure

a) Greet each client with a smile saying, “Welcome to Delgado Massage Therapy Clinic.”

b) Exercise genuine hospitality when greeting and directing your client to the massage area.

c) Have each client complete an intake form followed by a brief interview addressing the

form. Repeat clients will be asked for an update from the last visit.

d) Give your client instructions as to how to get ready for the massage: “Please undress to

your comfort level, lie on your back or on your stomach under the sheet. Let me know

when you are ready.”

e) Before beginning the massage, make sure your client is comfortable in the headrest,

bolsters are used properly and the temperature is ok. It is good to have a blanket

available.

f) After completing the massage, make sure that your client is okay. Before leaving your

client, instruct him or her to get up slowly by turning on his or her side and sitting up for

a minute before standing up to get dressed. Let the client know that you will be close by

if it seems that he or she is having trouble getting acclimated.

g) Always wait a moment then ask the client if he/she is okay once you have left the cubicle.

Student Massage Therapist Expectations (Page 2)

h) Escort the client to the sitting area. Encourage them to increase his or her intake of water

to flush out toxins that are now in the lymphatic system.

i) Document relevant information pertaining to the client and the session. Remember, this is

the time to develop good record keeping skills/habits.

IV. Confidentiality/Respect

a) Student demonstrates and maintains confidentiality of client information and records by

discussing the intake form privately and discreetly. Never disclose your client’s name

when posing questions or discussing your client or session.

b) Do not discuss sessions during clinic time unless it is with the instructor.

c) During the session, keep conversation to a minimum. Do not start a conversation; briefly

answer any questions asked by your client. If they are talking too much or too loud, ask

them to take some deep breathes and relax and try to enjoy the rest of the massage in

silence. Remember that idol chatting may indicate some level of an emotional release for

some, so tune in to your client to determine the best therapeutic response.

V. Scope of Practice

a) Determine the needs of the client and develop a plan within the scope of training to date.

b) Practice the techniques/theories based on the training that you have received to date.

Refrain from using techniques that you have not been trained in using.

c) If you come across an irregular mole or a bruise or “bump” that alarms you or makes you

wonder if the client knows about it, bring it to his/her attention before leaving the clinic.

Refer the client to his/her physician if necessary. Realize that people are not as aware of

their bodies or body markings as you may assume and it is in our scope of practice to

increase body awareness. Consult with the instructor when in doubt.

d) To ensure client satisfaction and technique effectiveness, tune in to the client to make

sure that they are okay. You may ask the client if the pressure is okay if you are unsure;

however, do not nag the client every 10 minutes.

TECHNIQUE

The student will discover and develop his or her unique gift as a massage therapist, perfect

draping techniques, and complete a balanced massage session, while practicing technical aspects

of massage therapy.

Specifically:

Timing

a) Resting position will begin precisely at the time of the scheduled massage. Followed by

the massage.

Student Massage Therapist Expectations (Page 3)

b) Depending on the technique being used, the massage may be a full-body session or a

partial body session. In either scenario, the massage will last 55 minutes, using the last 5

minutes for the client to rest, get-up and get dressed.

c) Create a rhythm and flow in your session giving the feeling of a balanced massage. Try to

spend equal time on each side of the body as well as on each limb, side of the back, etc.

II. Draping

a) Only the part of the body being worked will be exposed during the massage session. If

the client is hot, expose the client’s arms to cool him or her off.

b) Having a blanket readily available is smart and thoughtful, as many people get cold on

the table.

c) Be sure to have a breast drape (towel) ready for those clients who give the okay to work

the abdomen.

d) Never allow the client to put skin on the bare table material. The face rest and the bolster

should be covered.

III. Body Mechanics

a) Table height should be adjusted before each session, taking into consideration the client’s

physique as well as the type of massage that you will be doing. While the client is

completing the intake, you may adjust your table accordingly. Remember, too low is

usually better than too high.

b) Shifting your body weight, using the body as a machine will sustain you through each

massage as well as several sessions back to back.

c) Complete breathing with fluid motions are necessary to administer relaxing, effective

techniques.

d) Be aware of your parameters. Take care not to do things out of your personal abilities.

For example, if the client asks for deeper pressure and you are at your peak, remember

that it is necessary to allow the muscle time to let you in by using consistent pressure. It

is not therapeutic to go in too fast. If appropriate, you may educate your client by

explaining this dynamic.

e) Comfortable, supportive shoes

will assist in good mechanics.

I have read and agree to adhere to the Student Massage Therapist Expectations.

_________________________________________ _______________________________

Student Massage Therapist Date

Attachment B

Massage Therapy Clinical Protocol

For MSTH 151, 152, 153

The clinical is conducted in a professional matter at all times.

Food and drinks are not allowed in Room 139 or any room where massages are performed at any

time. Do not chew gum.

The client interview is to be conducted in privacy and kept confidential.

All students are to be in proper uniform (black scrub pants, white polo shirt with Delgado logo,

shoes and socks); hair neat and pulled back; nails neat and trimmed and all jewelry removed.

Please be aware of your breath and body odors.

Smoking is not permitted by students during the clinical.

Student massage therapists are responsible for client intake forms, SOAP notes and filing all

client folders.

Student massage therapists should have tables set up and sheets on fifteen (15) minutes before

clinic starts.

Student massage therapists are responsible for cleaning and putting table back in Room 139.

The instructor is responsible for walking around to observe and grade student massage therapists.

10.

The instructor/director is responsible for assigning a client to a student massage therapist.

11.

The Bursar’s Office is responsible for collecting all money; the program director, instructors,

and students are not authorized to collect funds.

12.

The instructor should check all massage rooms at the end of the night to make sure that all tables

are cleaned and supplies are back in the proper place.

13.

The instructor should review the client history with the student and give suggestions as to what

questions need to be asked, what special techniques may be required for the particular client, etc.

14.

The director will log all appointments during regular office hours 8:00 a.m. - 4:30 p.m. Clients

should call 361-6417 for an appointment.

Attachment C

Massage Therapy Client History Form

Name:_______________________________________ Date:_____________________________

Address:__________________________________________________________________________

_________________________________________________________________________________

Telephone Number: Home _________________________ Other: _____________________

Occupation:_______________________________________________________________________

In case of emergency, who may we contact:

Name____________________________________ Relationship _____________________________

Phone: _________________________________

Have you received a professional massage before? ________yes _______no

Primary Reason for Appointment:_______________________________________________________

__________________________________________________________________________________

If you are a female, are you pregnant? ________yes ________no

Are you currently under a physician’s care? ________yes ________no

If yes, why? _________________________________________________________________________

List all previous injuries/surgeries and their respective dates? (ex. Sprains, strains, whiplash,

fractures)____________________________________________________________________________

____________________________________________________________________________________

Are you or have you recently experienced any pain? ________ yes _______no

If yes, please describe the pain and the location: _____________________________________________

____________________________________________________________________________________

Please review list and circle all that apply:

headache/migraine tumors asthma low/high blood pressure

diabetes depression heart problems tension

blood clots cancer fatigue AIDS/HIV

varicose veins sleep difficulties seizures sinus problems

painful joints disc problems skin disorders

Others:_______________________________________________________________________

Check medications you are taking: _____Vitamins _____Herbs _____ Sleeping Pills

_____Aspirin/Anti-inflammatory _____Muscle Relaxants _____Pain Reducers

_____Anti-anxiety/Depressants Others: ___________________________________

Please list all medications:_______________________________________________________

_____________________________________________________________________________

Massage Therapy Client History Form (Page 2)

Clinical Procedures for the Student Massage Therapist

Student massages will last from 50-60 minutes and include work on the head, face, neck,

shoulders, arms, back, abdomen, upper chest, legs, hands and feet.

The student massage therapist may use several different techniques throughout the massage

including effleurage (smooth gliding), kneading, rocking movement, movement reeducation,

range-of-motion, and application of pressure to specific points on the body.

In clinical II and III, the student massage therapist, may be able to customize your massage to

meet your needs and requests taken from the client intake form.

Most massage techniques are usually preformed with the client unclothed, to his or her level of

comfort, on a comfortable massage table. Louisiana law states “the genitalia and buttocks for

men and the genitalia, buttocks and breast for women must be covered at all times during the

massage.” The client will always be properly draped with a sheet, and only the area being

massaged will be exposed.

The student massage therapist may use oils, lotions, and heat during the massage.

Client confidentiality from the client intake form and conversations with the client will be

adhered to at all times.

Respect for the client’s boundaries with regard to privacy, disclosure, exposure, emotional

expression and beliefs will be adhered to all times.

The student massage therapist may only use those techniques practiced in class and within the

scope of practice of a student massage therapist at that time.

All clinics will be monitored by the instructor teaching the course and/or the director of the

program.

I have answered all of the above questions as completely and honestly as possible. I understand

that I will be receiving a massage as part of student clinical training, and I have read the

techniques and procedures that will be used. It is my responsibility to inform the student

massage therapist of all of my health conditions and to keep the Delgado Massage Therapy

program staff and students updated on any changes in my health.

________________________________

___________________

Client Signature Date

_________________________________

______________________

Student Massage Therapist Date

Attachment D

Release of Liability/Express Assumption of Risk

In consideration of being allowed to participate in the Delgado Community College Massage Therapy

Program clinic, I do hereby waive, release and forever discharge the State of Louisiana, the Louisiana

Community and Technical College System, Delgado Community College, and its students, faculty and

staff from any and all responsibilities or liability for injuries or damages resulting from my participation

in the activities of the Delgado Community College Massage Therapy Program clinic. I do hereby

further declare myself to be physically sound and suffering from no condition, impairment, disease,

infirmity, or other illness that would prevent my participation in the activities of the clinic.

I realize that there are risks of injury that may arise due to my participation in this activity and that it is

not possible to specifically list each and every individual injury risk. However, knowing the material

risks and appreciating, knowing, and reasonably anticipating that injuries are a possibility, I hereby

expressly assume all of the delineated risks of injury, all other possible risks of injury or death, which

occur by reason of my participation.

I have had the opportunity to ask questions. Any questions I have asked have been answered to my

complete satisfaction. I subjectively understand the risks of my participation in this activity, and

knowing and appreciating these risks I voluntarily choose to participate, assuming all risks of injury or

even death due to my participation.

__________________________ ___________________

Client Signature Date

__________________________ ___________________

Witness Date

Attachment E

“SOAP” Notes

Date: ______________________

Student’s Name: ______________________________________

Client’s Name: ________________________________________

Subjective Evaluation

_________________________________________________________________________________

Objective Evaluation

_________________________________________________________________________________

Application

_________________________________________________________________________________

Plan/Progress

_________________________________________________________________________________

Attachment F

Student Massage Therapist

Evaluation Form

Name of Student Massage Therapist: ___________________________

Date: ______________________

Please take the time to fill out the student massage therapist evaluation form. Our students are in clinic

to learn and adapt to different situations. Your feedback as a client will be beneficial to the student and

the instructor. Your suggestions and /or praise of students will guide and develop our students to

become future massage therapists. Thank you for your time and come again.

Give one (1) recommendation for improvement:

Give one (1) positive feedback to the massage therapy student:

The thing I like best about the massage is:

The thing I like least about the massage is:

Give one (1) positive feedback to the student massage therapist that made your experience

receiving a massage comfortable and beneficial for you.

Please offer any other suggestions, praises, and/or other comments below:

Thank you.