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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
2
ADDITIONALINFORMATION
IsthisyourfirstexperiencewiththeFeldenkraisMethod? Circleone:YesorNo
IfNo,whereandhowhaveyouexperiencedtheFeldenkraisMethod?
Whatisyourmainreasonforseekingtreatment?
Wasthereaspecificincidentthatcausedyourissueorconcern?
Haveyousoughtmedicalassistance?Circleone:YesorNo
IfYes,whatwastheresultorrecommendation?
Haveyoueverbeenhospitalizedorhaveyouhadanysurgicalproceduresrelatedorunrelatedtothisissue?
Whatconditions,activitiesorsituationsseemtomaketheproblemworse?
Areyoucurrentlytakinganymedicationsorreceivingpsychiatrictreatment?Ifso,pleasespecify.
Isthereanyotherinformationyou’dliketosharewithus?
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
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_______
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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