Feldenkrais in Jamaica Plain
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Sounder Sleep System Training
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Contact Me
Home
About
Blog
Individual Lessons
Somatic Musicians' Lab
Feldenkrais in Jamaica Plain
Sounder Sleep System Training
Group Classes
Series pages
Contact Me
New Student Intake
Please take a moment to fill out this form.
Name
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First Name
Last Name
Email
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Phone
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Pronouns
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he/his
they/them
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Please provide name and phone number of emergency contact.
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What brings your to Feldenkrais? Please briefly describe what you are currently experiencing, including onset and diagnosis (if applicable). How is this experience impacting your wellbeing?
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What do you hope to gain from the Feldenkrais Method? What do you most hope to have addressed?
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How do you spend your time? What activities do you do regularly?
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On a scale from 1-10, how would you rate your stress? (1 lowest, 10 highest)
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Please review this list and check those conditions that have affected your health either recently or in the past.
broken/dislocated bones
muscle strain/sprain
arthritis/bursitis
scoliosis
back problems
osteoporosis
asthma
diabetes type 1 or 2
high/low blood pressure
Ehlers-Danlos Syndrome or other hypermobility
insomnia
anxiety
depression
numbness, tingling
pregnancy
cancer
seizures
heart conditions, chest pain
joint replacement surgery, or other surgery
auto-immune condition
PTSD
eye surgery
orthostatic hypotension
deep-vein thrombosis
other (please elaborate)
Please elaborate of any condition you would like:
Please list any other services you are receiving (mental health, physical therapy, acupuncture, medical doctor/specialist):
Please list any medications your are currently taking:
How is the quality of your sleep?
Additional Information: It there anything else you would like me to know that I did not ask? Do you have any questions for me?
Please initial that you agree- I agree not to come into the office if I have Covid-like symptoms or have been exposed to anyone who has Covid-like symptoms in the past 5 days.
Thank you!