ERINFINKELSTEIN96355 Email Marketing -

Sound Movement Service LLC intake form for kids and families

Contact Info

Date *

Your Child's Full Name *

birthday *

Email *

Phone *

Address *

Parent Name *

Parent Email (if different than above)

Parent Phone (if different than above)

Second/Third Parent/Caretaker/Emergency Contact Name

Email

Phone

Siblings and Ages

About Your Child

Has your child done Feldenkrais® before? *

What brings you to the Feldenkrais Method for your child? How do you hope this will help? *

We don't treat illness but rather create options to learn how to move and live in a more wholesome way. Within this context, does your child have a diagnosis and how do you feel that limited their options in their life? *

Hospitalizations and/or surgeries? *

What movements or situations have you been told not to do by a medical professional? *

What brings your child joy? *

Are there any triggering aversions to avoid? *

Is your child in a wheelchair, fed. by G-tube, or use any other kind of assisted device? *

What therapies are you doing at this time? *

What therapies have you stopped, and why? *

Who referred you to me, or where did you hear about my services? I like to send a thank you. *

Terms and Conditions

Select the lists you wish to subscribe to *

Feldenkrais Newsletter from Sound Movement Services

Sound Movement Services Kids

By clicking below, you agree that the Feldenkrais Method® is an educational tool to increase somatically based functional movement, and does not replace medical advice. You are consenting to verbal and touch based Functional Integration® for your child. While this is the most gentle tool available, there is always an element of risk or injury to any movement modality, and you hereby release Sound Movement Services from any liability.

Consent and release of liability *

I Agree

By clicking below, you agree to the following cancelation policy: Lessons that are canceled in less than 48 hours (two full days) for any reasons other than illness or death in the family, will pay the full session fee. I often have a waiting list and families coming from out of town for lessons, so I want to ensure children and their families get the times they need.

Cancelation Policy *

I agree

Social Media and my email list is a wonderful way to get the word out about this life-changing education. If you would like to take pictures and video in the lesson, please check with me first so I can review the content and ok it. You child's privacy is my top priority, so please choose the option that you are most comfortable with below. Additionally, I enjoy you sharing any videos or pictures you might have of our work together with me directly, so that I may keep a folder to view as your child works with me over the years. You can follow me on facebook.com/SoundMovementServices, ig @soundmovementservices, twitter @erinfinkelstein, LinkedIn https://www.linkedin.com/in/erinfinkelstein/

Social Media/Email List Preferences *

Please never share any photos or videos of my child

Please check with me before sharing any photos or videos of my child

Feel free to share photos or videos under 30 seconds of my child

Payment Method

Due at time of service. I accept all major credit cards, venmo, ESA (mark ESA in box above) check, or cash. Some HSA accounts seem to work, some don't, so contact your provider and set up a pin for use and we can try it, but have a backup payment ready if it doesn't accept it.

Anything else you'd like me to know?

Thanks for your submission. After clicking the button below, you'll receive an email with directions. The next page will direct you to my booking site. If you are interested in a 6 - 10 lesson intensive, call or email me directly to book: info@erinfinkelstein.com, 916-296-9068. Best, Erin Finkelstein