Intake Form

What kind of treatment are you looking for? *

Choose the option that best matches what you need today. This helps your therapist plan your treatment. Please keep in mind that some conditions may require more than one session to achieve the best results.

JUST FIX ME – SPECIFIC PAIN / PROBLEM: Choose this if you have a specific painful area, injury, or problem you want the therapist to focus on. Weekly visits may be recommended until your pain and symptoms improve. A treatment package is highly recommended, and a progress form will be completed at each visit to track your improvement. MAINTENANCE & LONGEVITY – FULL BODY / GENERAL TIGHTNESS: Choose this if you do not have a specific painful problem and mainly want a full-body treatment for general stiffness, tightness, mobility, recovery and long-term wellbeing. Monthly maintenance visits are recommended.

Gender *

Male Female

Would you like to have conversation with therapist during treatment? *

Yes No Maybe

How much of pressure do you prefer? (1-10) *

No pressure Very firm

How bad is the pain? (1-10) *

No pain Worst pain you have in your life.

Last 4 digits of your Phone Number *

Full Name *

Age *

Occupation *

Sports/Exercise/Hobbies *

Where is your main pain/problem? *

Head Neck Shoulder/arm Low Back Hip/knee/ankle Maintenance/multiple areas

Body pain map drawing *

Upload a file or drag and drop

50 MB limit per file

Any surgery or injury that therapist should know and have we asked everything that is important to you? *

eg. got hip surgery 1 month ago, on blood thinner medication