New Client intake formThank you for taking a few minutes to answer these questions: 1. Personal Information: Name * First Name Last Name Email * Phone * (###) ### #### Birthday Preferred Gender Pronouns: she/her he/him they/them other (space provided below) prefer not to answer If you answered 'other' please provide your gender pronouns below: Please provide name and phone number of an emergency contact: 2. Background & Motivation: What brings you to Feldenkrais? Please briefly describe what you are currently experiencing, including onset/diagnosis (if applicable). How is this experience impacting your well-being?: What do you hope to gain from the Feldenkrais method? What do you most hope to have addressed? How do you rate your current level of activity? Sedentary/Very Inactive Somewhat Inactive Somewhat Active Extremely Active How do you spend your time? What activities do you do regularly? On a scale of 1-10, how would you rate your stress? (1 is lowest, 10 is highest) Please review this list and check those conditions that have affected your health either recently or in the past: broken/dislocated bones muscle strain/sprain arthritis, bursitis scoliosis back problems osteoperosis asthma diabetes type 1 or 2 high/low blood pressure Ehlers-Danlos syndrome or other hyper-mobility insomnia anxiety depression numbness, tingling anywhere pregnancy cancer seizures heart conditions, chest pain joint replacement surgery or other surgery auto-immune condition Please elaborate on any condition you'd like: Please list other services you are receiving (i.e. mental health therapy, physical therapy, MD, ND, acupuncture, medicationetc.): 3. Additional Information: Is there anything else you would like me to know about you that I did not ask? Do you have any questions for me? 4. COVID-19 precautions: Masks are now optional for sessions. I will match you if you come in with a mask. Are there any other COVID precautions that would feel supportive? 5. Please Initial that you agree--COVID Precautions: I agree not to come in to the office if in the last 10 days I have experienced COVID-19 like symptoms of have been exposed to anyone who may have COVID like symptoms * 6. Please Initial that you Agree-- Liability Waiver: I acknowledge that the Feldenkrais Method and Awareness Through Movement lessons are educational and not a substitute for medical diagnosis or treatment. I take responsibility to let the teacher know about any physical limitations I may have and to honor my own limitations. I hereby release Michelle Huber from responsibility for any injuries I may sustain * 7. Please initial that you agree-- Cancellation policy: There will be no charge if appointments are cancelled 24 hours in advance. Cancellations with 24 hours of the scheduled time will be charged the full fee. If you have a COVID exposure or there is inclement weather and you need to cancel with less than 24 hours notice, you will also not be charged. Arriving more than 15 minutes late to the appointment will be considered a no show- and a full fee will be charged * Thank you so much for taking the time to answer these questions, please update Michelle if there are any changes.
