General Movement Intake Form for New Clients

Phone

This field is for validation purposes and should be left unchanged.

Approx Height (Inches)*

Approx Weight (Lbs)*

Legal Guardian (if Applicable)

Legal Guardian Phone

Emergency Contact Name*

Emergency Contact Phone*

Name of referring professional / Or name of person Kathleen can thank (if applicable):

How did you hear about Kathleen (other)

What is the location or name of the event?*

Cancellation Policy

Your appointment time is reserved just for you. A late cancellation or a missed session leaves a hole in Kathleen’s day that could have been filled by another client. As such, she requires at least 24 hours’ notice for any cancellations or changes to your appointment. Clients who provide less than 24 hours’ notice, or miss their appointment, will be charged a cancellation fee equal to the cost of the cancelled appointment. I am aware of, and I agree to the above Cancellation Policy.

Consent to Be In The Keller Method Vitality Database

KMV deeply respects your privacy. Your address will never be shared. KMV only would communicate with you professionally about you and your sessions, KMV business updates that apply to you and pertinent information that may directly interest or help you specifically.

In relation to the type of modality you are going to be doing with Kat. Have you ever done any structured Pilates, Fascial or Functional Fitness or Self Myofascial Release before? If possible please indicate when and with whom.*

In which activities and sports do you currently engage? State how frequently.*

If you have an occupation, what do you do? Are you currently working?*

What are the physical requirements of your occupation, volunteer or personal interest activities? (e.g. sitting, computer work, standing, bending, lifting)*

What are your fitness or health goals through learning Pilates, Fascial or Functional Fitness or Self Myofascial Release?*

If there are any movement(s) that your doctor or therapist have told you NOT to do, please share what that is.

Have you ever had a major illness, accident or surgery? If yes, please briefly explain.

Ongoing therapies (e.g. physio, chiropractic, massage) and indicate practitioner(s)’ name(s).

Check currently relevant or relevant to your history. Please provide specific details if necessary.

Carpal Tunnel Details

Chronic Fatigue Details

Digestive Issue Details

Fibromyalgia Details

Joint Problem Details

Neurological Conditions Details

Osteoporosis Details

Spinal Condition Details

Systemic Condition Details

Thoracic Outlet Syndrome Details

Is there anything else not covered in this form that you want Kathleen to know?

This field is for validation purposes and should be left unchanged.

General Movement Intake Form

Policies & Consent

Cancellation Policy

Consent to Be In The Keller Method Vitality Database

Activities

Health History

Check currently relevant or relevant to your history. Please provide specific details if necessary.

View Kathleen's Speaker Packet