Connect With Us

Intake Form

    Name

    • First
    • Middle
    • Last
    • Preferred

    Event Information

    • Phone
    • Secondary Phone
    • Email*
    • Address
    • Occupation
    • Employer
    • Emergency Contact
    • Emergency Phone
    • Relationship

    Client / Practitioner Role

    Briefly describe the Series, workshop, or event and how you were in relation to your Practitioner:

    I am hoping to receive from my Series or Individual Session:

    Better PostureOptimal Physical PerformancePhysical HealingLifestyle CenterednessSomatic BalanceEmotional Development

    Have you received structural Integration Before?

    YesNo

    What type of treatments have you received in the past?

    MassagePhysical TherapayMedical SupervisionAccupunctureSurgeryPrescription MedicationChiropractic CareHolistic CareHerbal Supplements

    Medical History

    Please select any area you would like to improve, have previously injured, or would like to discuss with practitioner

    Please select if you have any of the following:

    Blood Clots (LegsorLungs) CancerLow Back Pain AIDS/HIV HepatitisShortness of BreathCurrently Pregnant

    Reproductive (System) ChallengesPinched NerveSciatic Pain DizzinessHeadaches/MigrainesArthritisFibromyalgia Herniated/Bulging/Ruptured DisksUnstable/Weak MusclesDifficulty Sleeping Mentally Restless Anxiety/Depression Suicidal Tendencies Easily Angered Constipation/Loose Stool Disordered Eating Digestive ProblemsLow EnergyOsteoporosisWarts, RashesOther Skin InfectionsSeizuresAllergies (food,latex,seasonal)DiabetesTuberculosisMuscle SpasmsTrauma






    Acknowledgement & Consent

    I, here by acknowledge and consent to the following:

    I understand the purpose of Structural Integration is to align and lengthen the body on its centerline and in space. Alignment occurs through a series of physical contacts, body ­centered education, and movement training. Structural Integration is a type of bodywork focus in g on the fascia. Fascia is the connective tissue that surrounds the muscle.

    I understand Center for Length is not involved with the treatment of disease of any kind; nor does it substitute for medical diagnosis or treatment when such attention is deemed necessary by a licensed physician. Nothing said or done by the Center for Length should be misconstrued as such. In addition, I understand that any relief of physical or emotional symptoms is coincidental in the centering of the physical body and not the direct aim of Structural Integration. Center for Length does not bear any responsibility for any medical or emotional condition occurring while receiving, but otherwise not related to Structural Integration.

    I understand it is necessary for my practitioner, operating through CenterforLength, to touch my body in an appropriate manner in order to assist me in my Structural Integration experience. I give CenterforLength my permission and consent to physically assist my body in the Structural Integration session. I further understand that I may, at any time, revoke such permission and consent, and can choose to discontinue the session and any further Structural Integration appointments. I understand that the revocation of my involvement in Structural Integration does not release me from the cancellation policy.

    I understand that CenterforLength always acts and operates in support of its Mission: to spread the teachings of Dr. Ida P.Rolf through the continuing education and practice of Structural Integration. To accomplish it's Mission, CenterforLength works with students, apprentices, mentees, workshop participants, and other individuals pursuing advanced Structural Integration education. I further understand that a student (or students) might be physically present for my Structural Integration sessions, but will never touch me without additional consent