Intake Form

Rolfing® Intake Form

Please fill in this form to get the most from your Rolfing sessions.

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Age (not a required field, but it is useful info for me) *

Are you pregnant? (Please let me know if you become pregnant, even if it's early days) *

Yes No (Men please take this option)

Please tell me why you have decided to come for Rolfing. Please include the things you are looking for help with. *

Let me know about your general health. *

If there's anything else that you want to let me know or ask me, use this box. *

Terms and Conditions

Cancelation Policy
I really appreciate 48 hours notice of cancellations. For cancellations with less than 24 hours notice (short notice) and for no-shows, I charge £20 to cover room hire costs and my time. The £20 charge is important for maintaining a good therapeutic relationship, so please use the bank details in my booking email to make payment in event of a short notice cancellation or no-show, then contact me to rebook.

Paying for sessions in advance
If you decide to pay in advance for 10 or 4 sessions then change your mind about working with me, I charge my full rate for the sessions we have done and refund the balance upon request.

Terms and Conditions agreement *

I agree

Submit