First Appointment Form

Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Mobile Phone

(###)

###

####

okay to communicate via text?

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you experienced MFR, Yoga, or Somatic Experiencing before?

Yes

No

Are you currently under the care of a physician and/or mental health provider?

Yes

No

I understand that the services provided by Robin Rizzuto is for the purpose of stress reduction and pain management. Robin Rizzuto does not diagnose illness or disease or any other disorder and she does not prescribe medical treatments or pharmaceuticals.

Agree

I understand that treatment with Robin Rizzuto is not a substitute for medical examinations or medical care and that it is my responsibility to continue working with my medical care providers as needed.

Agree

I have stated all my known health conditions and I will update Robin Rizzuto of any changes that arise in my health status.

Agree

I understand that cancellations must be made at least 48 hours in advance to avoid financial responsibility for scheduled appointments. Exceptions for emergencies or extenuating circumstances may be made at Robin Rizzuto’s discretion on a case-by-case basis.

Agree

Date

MM

DD

YYYY