Rolfing SI New Client Form
Name
DOB *
Contact Number *
What brings you to Rolfing and what do you hope to experience/gain from the work? *
Have you had Rolfing before? *
Do you have any current or previous medical conditions? What treatment have you recieved? Please describe *
Are you currently receiving any other forms of complementary therapy, psychological therapy or medical treatment? Please describe *
Please describe any old injuries/ fractures/significant accidents you have experienced? Include dates and treatment you have received. *
Are you on any medications? *
Please list any operations, accidents, injuries or serious illness or trauma that you have had *
Additional information and/or comments you would like to add: *
What to wear
Rolfing sessions will take place in your underwear on a treatment table and in movement. Please wear underwear that is not restrictive to breathing and that you feel comfortable moving in.

Each session will involve a body reading where we track changes that may be occurring in the body. Body reading will involve standing, sitting and often walking.

Cancellations and postponements
Missed appointments will be charged at full rate if less than 48 hours notice is given.

Please phone or text as soon as possible if you are unable to keep your appointment — if I can fill the time-slot there will be no charge.

By the same token, if I make a scheduling mistake, or cancel under the 48 hour policy, your next session would be free.

Fee's
Rolfing Session cost £70 payable by BACS or by cash.
Consent
Rolfing Structural Integration is a process that takes place over a number of sessions with the purpose of creating greater body awareness and improved capacity for free movement through a process of direct manipulation, movement and perceptual education.

A Certified Rolfer™ does not treat, prescribe or diagnose illness, disease, any physical or other related ailment of the person seeking Rolfing SI. Nothing said or done by the below named Rolfer should be understood as counter to this statement.

I give Nico Thoemmes my permission and consent to work with me in such a way as to restore and establish balance and ease in my physical body through the process of Rolfing Structural Integration. I further understand that I may at any time revoke such permission and consent, and can choose to discontinue the session and series of Rolfing.

Consent to undertake Rolfing with Nico Thoemmes *
Date *
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