Rolfing™ & Yoga Edinburgh

Move Breath Feel Be

Please submit your intake form here. Please include as much detail as you wish. During the first session we will have time to talk about the info you have given here. All info submitted is strictly confidential.

Your Name: *

Your Email: *

Best Phone number: *

Address: *

Date of birth: *

Height & Weight: *

Occupation: *

Describe your physical state at present include any physical discomforts: *

Describe any physical injuries, emotional trauma or disabilities that you would like to work with: *

Why are you seeking out Rolfing, what goals do you have? (Please take time to think about this one) *

Please tell me about any diseases or conditions you are receiving medication or treatment for? (allergies, diabetes, depression, cancer or something else): *

Tell me about an other therapists you are seeing at the moment: *

Sports & physical activities that you are doing at the moment (If there is something you would like to take up please add it as a goal): *

Have you had Rolfing work before? Please give details when, where, how many sessions? *

Please use this box for anything else you would like me to know:

Do you wear dentures? *

Do you wear contact lenses? *

For women only, during some session we will work with the abdomen, this can affect the reproductive system.

Are you Pregnant?

Are you trying to conceive? Please let me know at any stage if you may have conceived

Do you have a IUD (coil)?:

Cancelation Agreement: If you miss an apointment or cancel on the same day, then you agree to pay £20 before continuing the sessions. *