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Rolfing Intake Form

Michael (Moylan) Ryan.

Rolfing Structural Integration Practitioner.

I fully understand the purpose of Rolfing Structural Integration is to balance and align the

physical body so it is supported and maintained by gravity in a three dimensional space.

This is done through direct manipulation and education so that greater ease and freedom of

body movement is achieved.

I understand that Structural Integration 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 Rolfing practitioner does not treat, prescribe, or diagnose an illness, disease, or any other physical or mental disorder of the person. Nothing done or said by the Rolfer should be misconstrued to be medical advice or psychotherapy as such.

I understand it is necessary for the Rolfer to touch my body in order to assist me in establishing balance and alignment in the body.

I give Michael (Moylan) Ryan Rolfing, my permission and consent to do all things necessary in helping me establish balance and alignment, including but not limited to touching my body.

I give the Rolfer full privilege and license to work on my body in such a way to restore and

establish balance and alignment therein.

Furthermore, I understand that any relief of physical or emotional symptoms is coincidental in the organization of the total human being and is not the basic goal of structural integration.

Date

Signature

Signature

Health Questionnaire

Date

Full Name

Address

City

State

Zip Code

Email Address

Phone Number

Date of Birth

Occupation

Height

Sex

Age

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Select All Conditions That Apply

Select All Conditions That Apply

Client Agreement and Release

I agree to receive manual and movement therapy from Michael (Moylan) Ryan Rolfing.

A variety of techniques and pressure levels may be used, including classic Rolfing techniques (Myofasical bodywork) as well as lighter soft tissue work (visceral and neural manipulation) and stretching. If I have any questions about the techniques being used, I will ask the Rolfing practitioner.

I understand that Rolfing and other manual therapy provided by Michael (Moylan)Ryan Rolfing is not a substitute for medical care or medical diagnosis. Rolfing and other manual therapies provided by Michael (Moylan) Ryan Rolfing are intended to ease areas of tension held by the body, support greater balance and increase body awareness. I understand that responses are individual and there is no guarantee of effectiveness or specific results.

I understand that I can stop the session or end therapy at any time. If at any point during the

session I feel uncomfortable with a technique or level of pressure, feel pain, discomfort or anxiety about whether the technique is right for me, I will let the practitioner know so the work can be adapted or stopped.

While bodywork and movement therapy are safe, I however understand it is always possible to experience an emotional response to manual therapy. This could manifest as a change in breathing pattern, intensification of somatic sensation or an upsurge of past memory held in the body.

PAYMENT AND CANCELLATION POLICY:

I agree to take responsibility in using the online facility to make payment and schedule my sessions. If I cancel a session within 24 hours before the session, or don't show up for a session, I understand that I owe 50% of the session fee. (If you need to cancel, please try to do so as far in advance of the session as you can. Doing so, will allow someone else to schedule an appointment)

SICKNESS:

I agree not to come for a session if I am currently suffering an illness that can be spread through air or casual contact (eg. flu, strep, cold) or is someone in my household is in

the contagious stage of a sickness. This is important in protecting you, (if you are sick your body needs to devote its attention on getting better) and also to protect other clients. If you think you may be sick, please cancel in advance. If you wake up sick, let me know, the late cancellation fee will be waived.


Date

Signature

Signature

Please describe any broken bones, major injuries or accidents.

List surgeries.

Description as needed

List any medications you have taken in the past six months.

Are you currently being treated by a medical doctor, chiropractor or acupuncturist?

If so, for what condition?

Are there any activities from which you are restricted?

What type of exercise do you do regularly?

How many hours per week?

Are you or have you ever been involved in any self improvement programs? (Yoga, Tai Chi, Holistic health classes, Therapy, Counseling, Coaching)

What other types of Bodywork have you received?

How frequently?

Have you received Rolfing before?

If so, how many sessions?

What would you like to receive from these Rolfing sessions?

How did you hear about me?