Feldenkrais Intake

Feldenkrais Intake
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referred by:
Occupation
What is your reason for making this appointment?
Please be as specific as possible!
Is there pain involved with your reason for the appointment?
If there is pain, does it prevent you from doing things you would like to do?
What are these activities or movements?
Check any that apply to you:
Select any movement practices you regularly practice

Other
Please provide a brief history of your issue/concern:
Are there any other life concerns or previous stresses that may have contributed to this issue?
Have you, or are you, currently receiving other treatments for this?
What activities bring you relaxation, pleasure joy and/or fun?
Is your enjoyment of these activities limited by this issue?
What improvements are you seeking?
CLIENT RESPONSIBILITIES:

I understand that my feedback is essential. At any time, if I become uncomfortable or in pain, I must bring it to the practitioner's attention.

It is the client's responsibility to explain and discuss physical conditions with the practitioner and to notify her of any changes in their condition.

CANCELLATIONS:
Failure to cancel within 24 hours of your appointment will result in a full session charge.

Thank you for your consideration of Kachina's professional time.
I understand & accept the Responsibilities & Cancellation Policy

Please sign your name
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