New Client Intake Form (Page 2 of 2) in pdf

Upright Rolfing 

New Client Intake Form 

For Women: Are you pregnant? Yes ___ No ___

Trying to get pregnant? Yes ___ No ___

ANY HISTORY OF:

Please check next to any that apply to you.

___Heart Condition

__Cancer

__Birth Defects

___High Blood Pressure

__Diabetes

__Genito-Urinary Disorder

___Arthritis

__Respiratory Disorder

__Multiple Sclerosis

___Osteoporosis

__Asthma

__Mental/Nervous Disorder

___Ulcer/Digestive Disorder

__Epilepsy

Please elaborate on any checked answers to the history above

_________________________________________________________________________________________________

What is something you value about your current structure and/or body? ________________________________________

What are 3 wishes for your 10 series or Rolfing experience? ________________________________________________

_________________________________________________________________________________________________

Additional information and/or comments you would like to add: _______________________________________________

_________________________________________________________________________________________________

I fully understand the purpose of Rolfing Structural Integration is to balance and align the physical body so that it is

supported and maintained by gravity in three-dimensional space. This is done through direct manipulation and education

so that greater economy of body-movement is achieved. I understand Rolfing is not involved with the treatment of

disease of any kind, nor does it substitute for medical diagnosis or treatment when such attention is needed. The Rolfer

does not treat, prescribe or diagnose an illness, disease, or any other physical or mental disorder of the person. Nothing

said or done by a Rolfer should be misconstrued to be such. I understand it is necessary for the Rolfer to touch my body

in order to assist me in establishing balance and alignment in my body.

I understand that Rolfing Structural Integration is a process and is not effective as a “quick fix” for chronic complaints. This

process is interactive and requires practice and awareness from the client.

I understand that this work is most effective if the assigned “homework” and practices are incorporated into daily life.

IN CASE OF CANCELLATION: I agree to give 24 hours advance notice of scheduled session, or to assume

responsibility for payment of half the session ($55.)

SIGNED_____________________________________________________ DATE_______________________________

New Client Intake Form Page 2