Consent Form – Rolfing


Sandra L Jones, Certified Rolfer
Before you choose to use the services of a Certified Rolfer, please read the following information FULLY AND CAREFULLY.

GOAL: Our basic goal is to encourage people to become knowledgeable about and responsible for their own health, and to bring it to a personal optimum level. Rolfing is designed to improve your health, but is not designed to treat any specific disease or medical condition. Reaching the goal of optimum health, absent other non-nutritional complicating factors, requires a sincere commitment from you, possible lifestyle changes, and a positive attitude.

I fully understand the purpose of Rolfing is to balance and align the physical body so that it is fully supported and maintained by gravity in three-dimensional space. This is done through direct manipulation and education so that greater economy and freedom of body movement are achieved.

I understand Rolfing is not involved with the treatment of disease of any kind, nor does it substitute for medical diagnosis or treatment when such attention is needed. The Rolfer does not treat, prescribe or diagnose an illness, disease, or any other physical or mental disorder of a person. Nothing said or done by a Rolfer should be misconstrued to be such.

I understand it is necessary for the Rolfer to touch my body in order to assist me in establishing balance and alignment in the body .I give Sandra L. Jones my permission and consent to do all those things necessary in helping me establish balance and alignment, including, but not limited to touching my body. I give the Rolfer full privilege and license to work on my body in such a way as to restore and establish balance and alignment therein. Furthermore, I understand that any relief of physical or emotional symptoms is coincidental in the organization of the total human being and is not the basic goal of Rolfing. Since every human being is unique, we cannot guarantee any specific result from our programs.

HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider. A Rolfer is not a substitute for your family physician or other appropriate healthcare provider. A Rolfer is not trained nor licensed to diagnose or treat pathological conditions, illnesses, injuries, or diseases.


If you are under the care of another healthcare provider. Rolfing may be a beneficial adjunct to more traditional care, and it may also alter your need for medication, so it is important you always keep your physician informed of changes in your health program.

If you are using medications of any kind, you are required to alert the Rolfer to such use, as well as to discuss any potential interactions between medications and bodywork with your pharmacist.

COMMUNICATION: Every client is an individual, and it is not possible to determine in advance how your system will react to the supplements you need. It is sometimes necessary to adjust your program as we proceed until your body can begin to properly accept products geared to correct the imbalance. It is your responsibility to do your part by using your nutrition guidelines, exercise your body and mind sufficiently to bring your emotions into a positive balance, eat a proper diet, get plenty of rest, and learn about nutrition. You must stay in contact with the Rolfer so we can let you know what is happening and the best course of action.

You should request your other healthcare provider, if any, to feel free to contact me for answers to any questions they may have regarding nutritional therapy.

LICENSURE: A Rolfer is not licensed by any state. However, a Rolfer is certified by the Rolf Institute. I have successfully met all course requirements, including a written and practical exam. A license to practice Rolfing is not required in some states. Laws and regulations regarding certification and licensure requirements differ from state to state.

By my/our signature(s) below, I/we confirm that I/we have read and fully understand the above disclaimer, are in complete agreement thereto and do freely and without duress sign and consent to all terms contained herein.