New Client Intake Form

New Client Intake Form

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 / Province

Postal / Zip CodeCountry
Emergency Contact*

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

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

YesNoUnsure
Please list your injury and surgical history.
Please list any pertinent information; the more descriptive, the better.
What would you like to gain from your Rolfing sessions?
Be as specific and descriptive as you feel called to share.
Have you received bodywork in the past? If so, what kind?
(eg. chiropractic, massage therapy, acupuncture, etc)
Are you currently seeing a healthcare professional for current injuries or illnesses?
How did you hear about this practice?

Word-of-mouthReferralGoogle/onlineSocial mediaOther
If you had 3 wishes for how you would like to feel in your body, what would those wishes be?

Syzygy Rolfing® Company Policy:

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

*You will never be asked to fully disrobe (male clients are encouraged to dress in athletic or boxer 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 $20 fee. Cancellations with no notice will incur a $50 fee. These fees may be paid via an online invoice.

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 the best of my ability, 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

Health Information