New Client Intake Form

New Client Intake Form - Rolfing

All information is held confident. At no given point is information disclosed or shared without client’s written consent.
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.

Health Information
1. Are you currently taking any medications? If so, please list them.
2. Do you have any allergies? If so, please list them.
3. Is there any chance that you are pregnant?*

YesNoUnsure
4. Please list your injury and surgical history.
Please list any pertinent information; the more descriptive, the better
5. What would you like to gain from your Rolfing sessions?
Be as specific and descriptive as you feel called to share
6. Have you received bodywork in the past? If so, what kind?
(eg. chiropractic, massage, energy work, etc.)
7. Are you currently seeing a healthcare professional for current injuries/illnesses?
8. How did you hear about our services?
9. If you had 3 wishes for how you'd like to feel in your body, what would those wishes be?

Appointment
Sacred Spaces Company Policy:

Your client information will be kept confidential. Written authorization will be required in order for Sacred Spaces to release any of your information.

*You will never be asked to fully disrobe (male clients are encouraged to dress in athletic shorts and female clients are encouraged to dress in athletic shorts and a sports bra for Rolfing sessions).*

You may end the session at any time for any reason.

Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law.

Cancellation Policy:

We require 24 hours notice for any cancellation of appointments. Cancellations within 24 hours will incur a $50 fee.

Client Agreement:

I understand that Rolfing structural integration does not diagnose or heal any illness or disease.

I acknowledge that Rolfing structural integration is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for such services.

During my session, I agree to voice any pain or discomfort that I experience to my practitioner so they can adjust treatment as needed.

I have stated my pertinent medical conditions, and will update the practitioner of any changes to my health status.

I agree to the 24-hour cancellation policy.

By my electronic signature below, I agree to the policy and client agreement above.
Signature*

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New Client Intake Form - Rolfing

Health Information

Appointment