the feldenkrais functional integration institute...

Feldenkrais Foundation�134 W 26th Street, 2ndFloor�New York, NY 10001

212-727-1210

DearSirorMadam:ThankyouforyourinterestintheFeldenkraisFoundation’sLowFeeClinic.ThispopularclinicprovidesindividualFeldenkraisFunctionalIntegrationsessionsatareducedrateforthosewhocannototherwiseaffordtreatment.AppointmentsareavailableTuesdayandWednesdaymorningsfrom10am-12pmattheFeldenkraisInstituteofNewYork,inacomfortable,professionalsetting.

PleasecompletethefollowingLowFeeClinicApplicationinordertohelpusdetermineyoureligibilityforthisprogram.Thisisaneeds-basedClinicwithratesdeterminedonaslidingscale,rangingfrom$35.00to$75.00persession.PleasecompleteeachsectionoftheApplicationfoundonpages1-6ofthisdocument,andsubmitthetwoadditionaldocumentsthatarerequiredtosupportyourfinancialinformation.Thisincludesacopyofthepagefromyour2016TaxReturnlistingyourAGI(AdjustedGrossIncome)andacopyofyourlastpaystub.Wewillbeunabletoreviewyourapplicationifitisincomplete.

Onceyourapplicationhasbeenreviewedandyoureligibilityhasbeendetermined,wewillcontactyouaboutyourapplication’sstatus.Ifyouareapproved,wewillsendaParticipantContractforyoutosignandreturntotheFeldenkraisFoundationbeforeyoursessionsarescheduled.Pleasenotethatcontractsaresixmonths.Aftersixmonthsor12sessions(whichevercomesfirst),clientswillbeunabletoreapplytotheLow-FeeClinicforthreemonthstime.

Completedapplicationscanbesubmittedeitherbymailoremailto:

rebecca@feldenkraisfoundation.org RebeccaTeicheraSubject:LowFeeClinicApplication134W26thSt,2ndFloorNewYork,NY10001

Ifyouhaveanyquestionsabouttheapplicationprocess,pleasecontactme,at212-727-1210.

Welookforwardtoservingyou.

BeWell,

RebeccaTeicheiraProgramsandOperationsManagerTHEFELDENKRAISFOUNDATION134W26thSt,2ndFloorNewYork,NY10001

LOWFEECLINICAPPLICATION

1

PERSONALINFORMATION

FirstName,MiddleInitial LastName ☐ Male☐Female

☐ Other:_________________StreetAddress City,State ZipCode

HomePhone WorkPhone CellPhone

EmailAddress DateofBirth

DoyouhaveaPrimaryCareProvider?

Circleone:YesorNoIfYes,whatistheirnameandcontactinformation?

EMPLOYMENT&FINANCIALINFORMATION

Areyoucurrentlyemployed?Circleone:YesorNoAreyoua(circleone):DancerActorSinger

IfYes,whatisyouroccupationand/orwhereareyoucurrentlyemployed?

Whatwasyourtotalhouseholdincomeforthe2016taxyear?FilingStatus:MarriedorSingle

Whatisyourcurrentmonthlyhouseholdincome?

Whatisthetotalnumberofdependentsinyourhousehold?

Pleaseprovideuswithanyadditionalinformationdescribingyoufinancialcircumstancesthatmayinfluenceourdecision.

ATTACHMENTS

Inadditiontocompletingtheentireapplication,pleasesubmitthefollowingattachmentsalongwithyourapplication.Pleasenotethatbothattachmentsarerequiredandyourapplicationcannotbeprocesseduntiltheyarereceived:

• Onecopyofthepagefromyour2016TaxReturnlistingyourAGI(AdjustedGrossIncome)forthetaxyear• Onecopyofyourlastpaystub

LOWFEECLINICAPPLICATION

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ADDITIONALINFORMATION

IsthisyourfirstexperiencewiththeFeldenkraisMethod? Circleone:YesorNo

IfNo,whereandhowhaveyouexperiencedtheFeldenkraisMethod?

Whatisyourmainreasonforseekingtreatment?

Wasthereaspecificincidentthatcausedyourissueorconcern?

Haveyousoughtmedicalassistance?Circleone:YesorNo

IfYes,whatwastheresultorrecommendation?

Haveyoueverbeenhospitalizedorhaveyouhadanysurgicalproceduresrelatedorunrelatedtothisissue?

Whatconditions,activitiesorsituationsseemtomaketheproblemworse?

Areyoucurrentlytakinganymedicationsorreceivingpsychiatrictreatment?Ifso,pleasespecify.

Isthereanyotherinformationyou’dliketosharewithus?

LOWFEECLINICAPPLICATION

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REFERRALINFORMATION

Howdidyouhearaboutus?

HaveyoupreviouslyreceivedFunctionalIntegrationsessionsattheFeldenkraisInstituteNewYork?

Circleone:YesorNo

IfYes,whichPractitionerdidyousee?

HaveyoupreviouslyreceivedphysicaltherapytreatmentatPhysicalTherapy&Feldenkrais,NYC?

Circleone:YesorNo

IfYes,whichPhysicalTherapistdidyousee?

EMERGENCYCONTACT

FirstName,MiddleInitial LastName Relationship

StreetAddress City,State ZipCode

HomePhone WorkPhone CellPhone

APPOINTMENTREQUESTINFORMATION

PleasecheckoffthetimesblocksbelowthatyouwishandareavailabletoattendLowFeeClinicsessions.

LowFeeClinicHours

Tuesdays ☐10:00am-12:00pm

Wednesdays ☐10:00am-12:00pm

LOWFEECLINICPOLICIES

• Payment:Dueatthetimeofservice.• Scheduling:Werecommendscheduling2-3weeksinadvancetoensurethemostconvenienttimeforyou.If

noappointmentisavailable,uponyourrequestwewillputyournameonthewaitinglistandnotifyyouwhenanappointmentbecomesavailable.

• CancellationPolicy:Werequire24HOURNOTICEforanycancellationasweexclusivelyreservethat

LOWFEECLINICAPPLICATION

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appointmenttimeforyouandwouldliketooffertheappointmenttoanotherpatientifyouarenotabletokeepit.Pleaseallowampletimeforpublictransportationorinclementweather.A$35-$75cancellationfeewillbeappliedtoappointmentscancelledorbrokenwithout24HOURSNOTICEbasedonyoursessionrate.IfyoucancelTWO(2)timeswithlessthan24hoursnoticeyourcontractwillbevoided.Youmayreapplyafter6months.

• Rates&TimePeriod:Sessionratesaredeterminedonaslidingscalefrom$35.00-$75.00perhour.Afterreviewingyourapplicationwewillofferyouapre-determinednumberofsessionswithinatimeframe.Foryourmaximumtherapeuticbenefit,thesesessionsmustbeusedwithinthistimeperiod.Youarewelcometoapplyforadditionalsessionsonceallyoursessionsareusedoryoureachtheendofthetimeperiod.Anewapplicationmustbesubmitted1yearfollowingthedateofyourfirstapplication.

• ApplicationandSessionRenewal:Onceallthesessionsareusedand/orthetimeperiodexpires,youwillberequiredtowaitsixmonthsbeforesubmittinganotherpartialapplicationtoreceiveadditionalsessions.Inaddition,afullapplicationwillberequiredoneyearaftertheoriginalapplicationdate.

• Aboutthemethod:Feldenkraisisamovement-basedmethodoflearning;allLowFeeClinicpractitionersarecertifiedbytheFeldenkraisGuildofNorthAmerica.Basedonthefindingsoftheinitialsession,yourpractitionerwilldeterminethebestcourseofactionforyourtreatment.Thisplanmayhelpclarifyposturalalignment,patternsofmovementandself-use.Suchmovementlessonsmaybeperformedbythestudentfollowingverbalinstructionsorthroughgentlehands-onwork.Thepractitionermayworkwithareasofthebodyotherthanthespecificsiteofinjuryorpain.Ifyouexperiencediscomfort,physicalorotherwise,pleaseinformthetherapistoradministrativestaffwithoutdelay.Yourcomfortisoneofthenecessaryconditionsforlearningmoreoptimalwaysofmovingandtheoverallsuccessofthetreatment.

TREATMENTAUTHORIZATIONBysigningbelow,IcertifythatalltheinformationIhavesubmittedistrue.Iunderstandthatanyincorrect,incompleteorfalseinformationIprovidecouldresultintheterminationofthisapplication.IhavereadandunderstandtheLowFeeClinicpolicies.Name________________________________Signature______________________________Date_______

ACKNOWLEDGEMENTOFCANCELLATIONPOLICY

FunctionalIntegrationappointmentsbrokenorcancelledbytheclientwithoutatleast24hoursadvancenoticewillincuralatecancellationfee.ThesignaturebelowconfirmsthatIhaveread,understandandagreetocomplywiththecancelationpoliciesregardingFunctionalIntegrationwiththeLowFeeClinicaslistedonpage4ofthisApplication.Name________________________________Signature______________________________Date_______

LOWFEECLINICAPPLICATION

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WAVIER,RELEASEOFLIABILITY&ASSUMPTIONOFRISKInconsiderationofbeingpermittedtoparticipateinactivitiesatTheFeldenkraisFoundation,Inc’s“LowFeeClinic(“LFC”)andtoparticipateinthedescribedactivitiesofFunctionalIntegration®(“FI”)andAwarenessThroughMovement®(“ATM”),andworkshopswhereinFIandATMarepartofaprogramofFeldenkraisMethod®-relatedactivities,

I,_____________________________________,infullappreciationoftherisksinherentinsuchactivities,doherebycovenantnottosue,andherebywaive,releaseandforeverdischargeTheFeldenkraisFoundation,Inc.,itsdirectors,officers,agents,andemployees,fromandagainstanyandallclaims,demands,actionsorcausesofaction,forcosts,expensesordamagestopersonalproperty,orpersonalinjury,loss,orliabilitywhichmayresultfrommyparticipationintheaforesaidactivities.

Iacknowledgethatmyparticipationintheabovedescribedactivitiesisvoluntary.Ialsounderstandthatthereisnoguaranteeofasuccessfuloutcomeandthatitispossible,althoughrare,thatanincreaseindiscomfortmayresultfromsuchparticipation.

Iunderstandthefollowing:TheFeldenkraisMethod®isamovement-basedmethodoflearning.Feldenkraisisaneducationalmodalityandisnotasubstituteformedicaladviceortreatment.Duringthesession,thepractitionermayworkwithareasotherthanthespecificsiteofinjuryorpain.Ifyouexperiencediscomfort,physicalorotherwise,informthepractitionerwithoutdelay.Comfortisoneofthenecessaryconditionsforlearningmoreoptimalwaysofmovingandfortheoverallsuccessofthelesson.

IhavereadandunderstoodtheWaiverandReleaseofLiability&Assumptionofriskabove:

Name__________________________________Signature______________________________Date_______

Anypersonundertheageof18yearsorotherwiselegallydisabledmusthaveaparentorguardianco-signthisform:

Name__________________________________Signature______________________________Date_______