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ArT of Releasing Student/Client Questionnaire
Thank you for your interest in ArT of Releasing! Please fill out the form below so we can better serve you, and feel free to email
artofreleasing@gmail.com
with any questions or concerns. Thank you and I look forward to joining with you on this journey! -Kristin
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Email
*
Your email
Phone number
*
Your answer
How to you prefer to be contacted?
*
Email
Phone call
Text
Any of the above
Are you signing up for...
A free 30-minute consultation
A 60-minute Alexander Technique session
A 45-minute Alexander Technique session
A 60-minute Releasing session
unsure/other
Clear selection
What is your name (first, last)? How would you like to be addressed, and what pronouns do you use?
*
Your answer
Are you interested in AT or Releasing?
Alexander Technique (AT)
Releasing
both
not sure
Clear selection
What brings you to AT and/or Releasing? Physical discomfort or chronic pain? Emotional or psychological blocks? Desire to increase your performance?
Your answer
If you're interested in AT, what is your level of experience with the technique?
No prior experience with the Alexander Technique (AT)
In-person and/or online group class only (no individual lessons)
Fewer than 6 in-person and/or online private lessons
6 or more online private lessons
6 or more in-person private lessons
AT trainee (on track for teacher certification)
AT teacher
Not applicable, only interested in Releasing work
Other:
Clear selection
If you're interested in Releasing, what is your level of experience?
Not applicable, I am only interested in AT work
No prior experience with Releasing or the Sedona Method
Limited experience
Taken the Introduction to Releasing class
Some experience with group calls or classes
6 or more individual sessions
Releasing Coach or Teacher
Other:
Clear selection
Have you had any injuries, surgeries, accidents, allergies or illnesses (physical or mental) that may interfere or arise during AT or Releasing work? (please list and/or explain)
*
Your answer
Have you visited a medical professional for any/all of the health and medical issues you described?
Yes
No
Nothing to report on!
Other:
Clear selection
Is there anything you would like me to know about you before we work together?
Your answer
Will you need any accommodations for in person or online classes/lessons?
Your answer
If you are requesting lessons at the sliding scale/reduced rate: do you earn less than $60,000 per year and is your combined household income less than $75,000 per year? (If it is complicated and you'd like to share more please email me.)
Yes
No
N/A
Clear selection
If possible, please provide the name/number of an emergency contact:
Your answer
Where did you hear about Art of Releasing or Kristin? Who can I thank?
Your answer
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