Rolfing® Structural Integration Client Intake Form
Name: ________________________________________________________ Date: ______________________
Address: ______________________________________________________ Apt: ______________________
City/State: ____________________________________________________ Zip: _______________________
Telephone: (c)______________________ (h)________________________ w)_________________________
Email: ___________________________________________Would you like to be on my client email list? Y/N
Occupation: ______________________________________________________________________________
Employer: ________________________________________________________________________________
Date of Birth: ______________________Gender: M F Height: __________ Weight: ___________
Emergency Contact: _________________________Phone/Relation:__________________/______________
Please list the 3 main areas of your body that you wish to address. Describe any physical limitations or pain that
you are experiencing, its history, and any treatments you may have tried. Please list the goals you have for these
areas if the limitations were removed?
Area (1)
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Goals:
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Area (2)
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Goals:
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Area (3)
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Goals:
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What do you expect from the Rolfing process? Do you have any other goals?
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Please rate on a scale of 1 to 10 how much the Areas listed above affect the following:
(1-not affected, 10-greatly affected)
Happiness/Mood:
1 2 3 4 5 6 7 8 9 10
Work:
1 2 3 4 5 6 7 8 9 10
Relationship(s):
1 2 3 4 5 6 7 8 9 10
Sleep:
1 2 3 4 5 6 7 8 9 10
Sports:
1 2 3 4 5 6 7 8 9 10
Kids:
1 2 3 4 5 6 7 8 9 10
Recreation:
1 2 3 4 5 6 7 8 9 10
Other: ___________________
1 2 3 4 5 6 7 8 9 10
General Investigation of Aspects of Physical and Emotional Health
Mark any condition you presently have or have had in the past. If it’s resolved, note dates:
MUSCULOSKELETAL
Fibromyalgia
Arthritis (Osteo- or Rheumatoid?)
Osteoporosis
TMJ dysfunction
Strains, sprains or tendinitis
Carpal tunnel syndrome
Thoracic outlet syndrome
Scoliosis/Spinal Conditions
CIRCULATORY
Anemia
Thrombophlebitis
Heart disease
Low/High blood pressure
Varicose veins
Diabetes
Clotting disorders
Aneurism
INTEGUMENTARY
Boils
Fungal infections
Herpes simplex
Warts
Eczema
Psoriasis
Skin cancer
LYMPH, IMMUNE, URINARY
Edema
Hodgkin’s disease
Cancer
AIDS, HIV
Chronic fatigue syndrome
Lupus
Kidney stone
NERVOUS
Multiple sclerosis
Peripheral neuropathy
Post polio syndrome
Headaches/Migraines
Stroke
Seizure disorders
Reduced sensation
Vertigo
Anxiety/Depression/Panic
Attacks
DIGESTIVE
Cirrhosis
Ulcerative colitis
Diverticulosis
Gallstones
Hepatitis
Irritable bowel syndrome
Ulcers
RESPIRATORY
REPRODUCTIVE
Endometriosis
Ovarian cyst
Breast or Prostate cancer
Are you pregnant?
Cyclical Pain
Asthma
Emphysema
Sinusitis
Tuberculosis
ALLERGIES
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Do you have any of the following?
___ Contact Lenses ___Dentures/Removable bridge ___Orthodonture (braces) ___I.U.D
___ Cosmetic, please explain: _________________________________________________________________
Do you have any other condition that deserves attention?
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Please list any surgeries and major accidents or falls that you have had including the date, the location on your
body, reason for procedure, etc.
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Are you currently receiving any type of treatment (MD, Chiropractic, PT, Acupuncture, etc.)? Yes/No
If yes, please specify:
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Doctor or Practioner:_________________________________________Phone:__________________________
Doctor or Practioner:_________________________________________Phone:__________________________
Are you currently (or have you ever been) in psychotherapy? Yes/No If yes, since when? What for?
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Name of Counselor: _______________________________________Phone: ____________________________
Address of Counselor: _______________________________________________________________________
If you are currently in psychotherapy, does your therapist know that you are contemplating Rolfing? Yes/No
Are you using or have you used psychotropic medication (anti-depressants, sleeping pills, anticonvulsants):
Yes/No
If yes, please specify medication and dosage: ___________________________________________________
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Prescribing Doctor: _______________________________________________ Phone: __________________
Are you taking any other medication/herbs? Yes/No
If yes, please specify medication, dosage, and for what condition:
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Do you exercise? Yes/No
If yes, please specify what types of activities and how regularly:
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Do you feel that you have a good mind-body connection/awareness? Yes/No
Please make any additional comments that you think may pertain to the Rolfing Process, or if you have any
concerns, please address them here.
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Where did you learn about Rolfing Structural Integration?
Internet [ ] door ad [ ] phone book [ ] word of mouth [ ] If so, from whom? _____________________________
If other, please explain. _______________________________________________________________
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What to wear to the Rolfing Sessions
Most clients receive work in their underwear. Briefs are best for men; traditional panties and bra work well for
women. If you're not comfortable with this stage of undress, a two-piece bathing suit or a pair of short, cotton
gym shorts is a good choice. I can work with a variety of clothing, just keep the following in mind:
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You must be comfortable. Unlike massage, Rolfing requires you to get up from the table and walk around
periodically.
Clothing should not pinch or bind. If you can lie on the table and pull one knee to your chest without
resistance, you’re in good shape.
Clothing should allow me to view and work your upper legs, mid-back, and neck. It’s also a good idea to
bring some work-out clothes (shorts, yoga pants, tee-shirt, etc.) if we want to incorporate stretches using
yoga mats, balance balls, or other training equipment.
What NOT to wear
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Fragrance. Many of my clients are highly-sensitive to smells. Even pleasant ones. Sorry to ask, but please
refrain from wearing perfume or cologne when you come for a session.
Mosturizers, lotion or oils. Lotion on your skin makes it difficult to manipulate tissue layers effectively.
The day of your session, it is helpful if you refrain from applying any type of moisturizer that does not
completely absorb into your skin.
Also…
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Please don’t come in sick! Neither my other clients nor I want to get sick. Please contact me and I’ll be
happy to reschedule.
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ROLFING® STRUCTURAL INTEGRATION INFORMED CONSENT AND THERAPY POLICIES
I fully understand that the bodywork & movement education I will be receiving is for the purpose of gaining balance, ease,
and alignment of the physical body. This is done through direct manipulation and education so that greater economy and
freedom of body movement are achieved. I understand it is necessary for the Rolfer™/Massage Therapist/Yoga Instructor to
touch my body in an appropriate manner in order to assist me in establishing balance and ease in my physical body. I give the
Rolfing Practitioner/Massage Therapist/Yoga Instructor my permission and consent to do all those things necessary in helping
me establish balance and alignment, including, but not limited to touching my body. I give the Rolfing Practitioner/ Massage
Therapist/Yoga Instructor full privilege and license to work on my body in order to assist me in establishing balance and
alignment therein. I further understand that I may at any time revoke such permission and consent, and can choose to
discontinue the session and/or series of Rolfing.
I understand that the therapist does not diagnose illness, disease, or any further physical or mental disorders. As such, the
therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform spinal manipulations. I understand
that bodywork is not a substitute for medical treatment or diagnoses and that it is recommended that I see a physician for any
physical ailments that I may have.
I acknowledge that the information I have provided on this form is correct and current to the best of my knowledge. I
understand that it is my responsibility to inform the therapist of any changes to this information. I understand that if I
experience any unusual discomfort and/or pain during my sessions it is my responsibility to inform the therapist so that they
can adjust the pressure or technique being used. With all this in mind, I agree to receive Rolfing® Structural
Integration/massage/yoga or movement instruction and hold the practitioner harmless for any problem that might seem to
arise as a result of a therapy session.
I acknowledge that arriving in a timely fashion is my responsibility. I will give a minimum of 24 hours notice if I need to
change or cancel my appointment. If I am unable to give 24 hours notice, I agree that I am still responsible for the session fee. I
will pay a $25 fee for any returned check. If I have an illness, I agree to contact the Massage Therapist/Rolfing
Practitioner/Yoga Instructor so a decision can be made about rescheduling. Fees are due and payable at the time services are
rendered, unless prior arrangements have been made. I understand that an additional $15 may be added to my session fee for
scheduling a session last minute or in less than a 24 hour time period. I agree to come in clean and non-intoxicated. If
intoxicated I understand that I will not be provided a Massage/Rolfing/Yoga session and that I am responsible for the full
session fee.
Privacy Policy- All written records and sessions are kept strictly confidential and will not be shared with any outside
establishment, individuals, organizations, or medical facilities without explicit written consent from the client (you) or the
client’s legal guardian. Unless legally required by local, state, or federal subpoena, summons, or other court order. I
acknowledge that I understand my rights as the client receiving therapy services. I am aware that I can request an additional
copy of this document at any time.
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Client Signature
Date
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Therapist Signature
Date
CONSENT TO TREATMENT OF A MINOR: By my signature below, I hereby authorize
______________________________________to administer massage, Rolfing, or other bodywork techniques to
my child or dependent as they deem necessary.
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Signature of Parent or Guardian
Date
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