Chi Kung Massage - Intake

Chi Kung Massage is a somatic and energetic experience, allowing for release of physical tension, emotional and energetic blockages. As this release occurs, you are welcome to express yourself through sound and movement. The practitioner guides your body to drop into a state of deep relaxation and allows you to tap into your innate healing potential. When emotions, tension and stress get released, the body naturally creates the proper conditions for a deep healing to occur.

Even though the practitioner is leading towards a certain level of intensity and pressure, you are encouraged to communicate your needs for more or less pressure. In addition, since this modality works with a deep level of pressure, you are by no means expected to endure any pain. As soon as you experience discomfort, make sure you express it and allow your practitioner to adjust accordingly.

Based on your boundaries and comfort level, this modality may be inclusive of the entire body; face, skull, chest and buttocks, and may include the “cradle of life” (the genitals). You are always welcomed and encouraged to decide what your personal boundaries are and work with the practitioner to create a session that is tailored to your level of safety and personal need. When working on the genital area or when in need, the practitioner will wear latex-free medical gloves for the safety of both parties.

As part of this protocol, as soon as the massage portion at your feet is complete, the practitioner will leave the room briefly to wash their hands. This is a traditional part of the work and is used as a way to release any excess energy stored in the practitioner while working in this way.

Though Chi Kung Massage may include the genitals, it is a healing modality and not an erotic massage. While arousal and release may happen during the massage, it is not the final goal. The practitioner remains fully clothed at all times and all touch is one-way only (from practitioner to client). 

In order to help the practitioner create the best experience for you, please fill out the form below.


Please complete the form below 

Name *
Phone *
Date of Birth
Date of Birth
Do you have any back problems or spinal injuries?
Do you have any difficulty lying on your front, back or side?
Do you have any allergies to certain oils, lotions or skin products?
Do you wear contact lenses?
Do you have breast implants or any other body modifications that would require special consideration during the massage?
Are there any areas of your body where you experience chronic tension or pain?
Are you pregnant?
Are you currently on any medications?
Any STI's the practitioner should be informed of?
Please check any condition below that applies to you:
Skin Condition
Heart Condition
Open Sores / Wounds
Artificial Joint
Easy Bruising
Swollen Glands
Recent Accident / Injury
Recent Fracture / Surgery
Difficulty with Arousal / Orgasm
Erectile Dysfunction
Premature Ejaculation
I understand that Chi Kung massage is a one-way touch modality, and that the practitioner is not open to reciprocal touch at any point during the session.
I understand that non-latex medical gloves will be used for all genital touch for the safety of both parties