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Feldenkrais Foundation 134 W 26 th Street, 2 nd Floor New York, NY 10001 212-727-1210 Dear Sir or Madam: Thank you for your interest in the Feldenkrais Foundation’s Low Fee Clinic. This popular clinic provides individual Feldenkrais Functional Integration sessions at a reduced rate for those who cannot otherwise afford treatment. Appointments are available Tuesday and Wednesday mornings from 10am-12pm at the Feldenkrais Institute of New York, in a comfortable, professional setting. Please complete the following Low Fee Clinic Application in order to help us determine your eligibility for this program. This is a needs-based Clinic with rates determined on a sliding scale, ranging from $35.00 to $75.00 per session. Please complete each section of the Application found on pages 1-6 of this document, and submit the two additional documents that are required to support your financial information. This includes a copy of the page from your 2016 Tax Return listing your AGI (Adjusted Gross Income) and a copy of your last pay stub. We will be unable to review your application if it is incomplete. Once your application has been reviewed and your eligibility has been determined, we will contact you about your application’s status. If you are approved, we will send a Participant Contract for you to sign and return to the Feldenkrais Foundation before your sessions are scheduled. Please note that contracts are six months. After six months or 12 sessions (whichever comes first), clients will be unable to reapply to the Low-Fee Clinic for three months time. Completed applications can be submitted either by mail or email to: [email protected] Rebecca Teichera Subject: Low Fee Clinic Application 134 W 26 th St, 2 nd Floor New York, NY 10001 If you have any questions about the application process, please contact me, at 212-727-1210. We look forward to serving you. Be Well, Rebecca Teicheira Programs and Operations Manager THE FELDENKRAIS FOUNDATION 134 W 26 th St, 2 nd Floor New York, NY 10001

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Page 1: the Feldenkrais Functional Integration Institute offeldenkraisfoundation.org/wp-content/uploads/2012/11/L… ·  · 2017-07-17Feldenkrais Functional Integration sessions at a reduced

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:

[email protected] RebeccaTeicheraSubject:LowFeeClinicApplication134W26thSt,2ndFloorNewYork,NY10001

Ifyouhaveanyquestionsabouttheapplicationprocess,pleasecontactme,at212-727-1210.

Welookforwardtoservingyou.

BeWell,

RebeccaTeicheiraProgramsandOperationsManagerTHEFELDENKRAISFOUNDATION134W26thSt,2ndFloorNewYork,NY10001

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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

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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?

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LOWFEECLINICAPPLICATION

3

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

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LOWFEECLINICAPPLICATION

4

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_______

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LOWFEECLINICAPPLICATION

5

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_______


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