Lotus Structural Integration Client Intake Form

Client Intake Form

All information is held in strictest confidence. At no point is information disclosed or shared without client’s written consent. You may choose to skip answering any question that is not required if you feel it impinges on personal information you do not wish to disclose.

Full Name*

First NameMiddle NameLast Name

Phone*

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Occupation

Emergency Contact Name*

Emergency Contact Phone*

How did you find Lotus Structural Integration?*

1. Have you ever had Structural Integration work before?*

2. How does your body feel? Describe where you are experiencing any discomfort.

3. What are you wanting to get out of this work?

4. Have you had any surgeries? What type and when?

5. Are you currently under any medical treatment?

6. Describe any major injuries or traumas.

7. Describe the sports and physical activities you enjoy.

I hereby apply for a series of Structural Integration work.

I fully understand the purpose of Structural Integration is to balance and align the physical body so that it is supported and maintained by gravity in three-dimensional space. This is done through direct manipulation and education so that greater economy and freedom of body movement are achieved.

I understand Structural integration is not involved with the treatment of
disease of any kind, nor does it substitute for medical diagnosis or treatment when such attention is needed. Lotus Structural Integration/Scotus Dunshee does not treat, prescribe, or diagnose illnesses, disease, or any other physical or mental disorders. Nothing said or done by Lotus Structural Integration/Scotus Dunshee should be misconstrued as such.

I understand it is necessary for Lotus Structural Integration/Scotus Dunshee to touch my body in order to assist me in establishing balance and alignment in my body.

I give Lotus Structural Integration/Scotus Dunshee my permission and consent to do all those things necessary in helping me establish balance and alignment, including, but not limited to touching my
body. I give Lotus Structural Integration/Scotus Dunshee full privilege and license to work on my body in such a way as to restore and establish balance and alignment.

I understand that any relief of physical or emotional symptoms is coincidental in the organization of the total human being and is not the basic goal of Structural Integration.

Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Date