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Timothy Pleasants LCMT

Informed Consent Agreement and Client Policy Statement

I take pride in providing competent, customized therapeutic treatments to meet my clients’ individual needs. All of my clients are treated with respect and dignity, regardless of age, gender, race, national origin, sexual orientation, religion, socioeconomic status, body type, state of health, or personal habits. I stay current with certification requirements for massage therapists in the state of Virginia as well as keeping myself apprised of the latest information and techniques through reading, receiving regular therapeutic bodywork, and attending relevant workshops so that I may provide the most effective, well informed treatments possible.

 

What my clients can expect of me: 

  • Services are by appointment only. I keep my schedule flexible in order to best accommodate all of my clients’ lifestyles. 

  • A rate of $130 per hour applies. I accept cash, check, or card and payment is due at the time services are rendered unless other arrangements have been made prior to treatment. Tipping is not expected. Rates are subject to change at any time, however, no less than 30 days notice will be given prior to the effective date of change. I cannot provide direct billing of insurance as Massage Therapists are CERTIFIED by the Board of Nursing in the Commonwealth of Virginia, rather than LICENSED. I can provide a receipt for prescription reimbursement. 

  • All appointments are confirmed in advance via the clients’ preferred method. If I must cancel an appointment, I will do so within 12 hours whenever possible. In the event an emergency prevents me giving full notice, I will provide a courtesy discount of 50% to the client’s next scheduled session. If a client is dissatisfied with a treatment, and no other agreement can be made, a 50% refund of the treatment price will be honored.

  • I perform services ONLY for which I am qualified and able to do, and refer clients to appropriate specialists when necessary. 

  • Accurate records are kept and regularly reviewed. Your privacy and confidentiality are highly respected and all health information is maintained in a secure filing system and will only be disclosed with written consent by the client, except as required by law or for the protection of others. 

  • Clients’ modesty is maintained at all times during treatment sessions. Clients are draped at all times by a large sheet or blanket, and only the body part being treated will be exposed at any time. 

  • All equipment and supplies are kept clean and safe.

  • Personal and professional boundaries are respected at all times. 

 

What I expect of my clients: 

  • Be present. If you are under the influence of drugs or alcohol at the time of your appointment, the session will be cancelled, and you will be liable for payment of the session in full. It is not safe for a person under the influence of drugs or alcohol to receive massage.

  • Clients who are sick or on antibiotics may not safely receive massage. Your appointment will need to be rescheduled. Please do so within the Cancellation Policy time frame or you may be charged in full.

  • Payment is due at the time services are rendered unless other arrangements have been arranged prior to treatment. 

  • Provide complete and accurate health records and inform therapist of any changes as necessary. 

  • Be clean. The benefits of massage are optimized when the skin is clean. 

  • Sessions that begin late because the client arrived late will end at the scheduled appointment time and are full price. 

  • If you must cancel or re-schedule your appointment, at least 12 hours’ notice is required or you may be charged for the appointment in full. 

  • It is your responsibility to inform the therapist if you are uncomfortable at any time during your session. 

  • The services provided in this office are for therapeutic benefit only. Sexual harassment is NEVER tolerated. Any aggressive behavior, sexually suggestive comments or advances made by the client will immediately terminate the session. The client will be liable for payment in full and will not be allowed to schedule in the future. 

By completing the form below I give my agreement and consent to receive treatment from Timothy Pleasants LCMT

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