Alignment In Motion Rolfing® Client Intake Form

Thank you for taking the time to fill out this questionnaire. It is really helpful for me to get some background on your body’s history, as it will dial us in to the work we will be doing together. All responses will remain confidential. Your personal health information is protected under the HIPAA Privacy Rule.

Note: This form is used as a guideline for further discussion about your general health and well-being

Name *
Please describe, including approximate dates, sites of injuries and treatments:
Please feel free to ask questions at any time during the process. Client communication is vital to the work. I look forward to working with you !