Integrated Wellness — Patient Forms

Gorilla Massage Grant

Project #C5005701
Grant Approval Form
This form must be filled out and approved by the Grants Committee BEFOREfunds may be sent. An example of a grant would be a payment to a person in a disaster or distress situation, a handicapped person or a person belonging to a charitable class listed below.
Please note: We do not permit the parents of any child under age 18 to give grants to that child. We do not permit grants to be made to a spouse. We do not permit grants to be made to an employee by his employer. All other gifts in connection with an approved grant program will be tax deductible. Event fund raising can grant tax deductions for contributions minus the value of the event.
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Grantee Name:     Date: //
Grantee Address: _
Grantee City, State, Zip Code:
Charitable Class to which individual belongs: For example: elderly, handicapped or disadvantaged, medically needy, retired employees of charitable institutions or government persons whose civil rights have been violated, etc.
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Description of Situation:Please fill in below that which describes the situation surrounding the individual or diagnosis.
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Financial Details of the Proposed Grant Recipient: In the lines below, please provide the financial hardship of the proposed grant recipient. (unemployed, retired, restricted income, disability)
Income and description of current employment:
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Approximate Total of Funds Needed:_
(Please attach an itemized invoice from the provider.)
Age of the Proposed Grantee:_
Relationship of the proposed grant recipient to the Gorilla Massage Fund: Indicate here if there are any blood, marriage, adoption or employment ties between the donor and the proposed grantee. If “none”, please state.
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Signature of Grantee                                             Date
Agreement and Understanding: I, the Program Manager of this project at CDP, understand and agree that the discretion and control of funds donated to this activity are entirely under the authority of Congressional District Programs, Inc. The above request is a suggestion and not a mandate.
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Signature of Program Director                           Date

For CDP Office Use Only:

Amount of CDP Discretionary Funds Involved (if any) _

We the undersigned have reviewed this grant request and hereby give our approval or disapproval:

Signature: _______________ Date: _/_/_ Approved        Disapproved

Signature: _________________________ Date: _/_/_ Approved        Disapproved

Signature: _________________________ Date: _/_/___ Approved        Disapproved

Integrated Wellness Systems LLC.

585-292-6428

Client Information

In order to maximize the effectiveness and safety of your massage session, please take the time to carefully complete this questionnaire. This information will be treated confidentially. Your feedback is appreciated.

Name:_____________________________________________ DOB:_____________________ Referred By:______________________

Address: ___________________________________________ City::______________ Zip:___________

Occupation:______________________________________ Home #:_________________ Cell #:______________ Work #:__________

Email Address:____________________________________

Emergency Contact: ________________________________ Relationship _______________________ Phone #:___________________

Are you pregnant now or attempting to get pregnant? ( ) Y ( ) N Have you had a professional massage before? ( ) Y ( ) N

What are your goals/concerns for today’s session? ____________________________________________________________________

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Check any of the following that my apply _______ Stress _______ Pain ________ Stiffness ________ Other __________________

Please check any of the following conditions that you have now or had recently

____ allergies ____ headaches ____ sciatica ____ varicose veins

____ arthritis ____ sinusitis ____ fainting spells ____ high blood pressure

____ bursitis ____ neck pain ____ loss of balance ____ shortness of breath

____ cancer ____ chest pain ____ broken bones ____ menstrual pain/PMS

____ diabetes ____ blood clots ____ abdominal disorder ____ skin disorders/conditions

____ edema ____ heart condition ____ osteoporosis ____ numbness hands/feet

____ herniated disc

Please state any recent injuries, medical treatments or conditions (not listed above)_________________________________________

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Are you under medical care or supervision at this time? ( ) Y ( ) N If so what for? ___________________________________

___________________________________________________________________________________________________________

Are you currently taking any medication? ( ) Y ( ) N If so, please list: ____________________________________________

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Physician Name:_____________________________________________ Phone #:_________________________________________

Do you wear ( ) contacts, ( ) dentures, ( ) hearing aid?

Do you experience any difficulty lying on your ( ) back, ( ) front, ( ) side?

PLEASE READ THE FOLLOWING AND SIGN BELOW

I acknowledge that massage therapy is not a substitute for medical diagnosis and treatment.

I understand that payment in full is expected at the end of my session, unless prior arrangements have been made.

I understand I am responsible for payment of any appointment cancellation or forfeiture of gift certificate with less that 24 hours notice.

I understand that inappropriate actions or language is cause for termination of my session.

We reserve the right to refuse service to anyone for any reason.

I give my consent to receive treatment _________________________________________________ Date_____________________