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  • Health Questionairre & Consent Forms

    We are thrilled 💖 you have chosen to partner with us on your healing journey 🙏.

    Completing this secure HIPPA protected form prior to your first appointment helps us focus on you and getting you better, faster.

    * = required field

  • PATIENT INFORMATION

  • Patient Date of Birth*
     - -
  • Today Date
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How Did You First Hear About Us*
  • Online Platform
  • Sex Assigned at Birth*
  • Is Your Gender Identity the Same as Your Birth Sex?*
  • Utilizing Health Insurance Benefits?*
  • Format: (000) 000-0000.
  • Do You Have Secondary Insurance?*
  • Secondary Insurance Type*
  • Format: (000) 000-0000.

  • Unfortunately, we do not accept patients that have Medicaid as either their primary or secondary insurance and there are no exceptions.

    When you have two types of insurance, like Medicare and Medicaid, they must work together to make sure your medical bills get paid. So, when the cost of treatment exceeds what Medicare can pay, which is often the case, then cost sharing policy provisions kick in and we have to bill Medicaid which we don’t accept. We apologize for this inconvenience, and I wish we had better news for you. As a provider it is critical we follow certain insurance rules, otherwise we will almost certainly face legal and financial consequences that would shut the practice.

  • SYMPTOMS & GOALS:

  • PREGNANCY:

  • Currently Pregnant?

  • Important: 

    Pregnancy:

    • 1st trimester: External assessments may be performed if needed, no doctor's note required.
    • 2nd and 3rd trimesters: Internal assessments require a doctor's approval or referral.

    Postpartum:

    • No doctor's note needed.
    • Internal assessments are conducted after a minimum 6-week clearance from your OB/GYN or midwife following your postpartum check-up.

  • DISCOMFORT FEEDBACK:

  • Describe Pain Type (tick all that apply)

  • BLADDER:

  • BOWEL:

  • Common Stool Consistency (tick all that apply)
  • Can you fully empty your bowel?
  • Experience pain or discomfort with bowel movements?

  • SEXUAL ACTIVITY:

  • Experience Pain With Orgasm?

  • MEDICAL HISTORY:

    Check current, previous, or n/a for diagnoses

  • Rows
  • Rows

  • SURGICAL HISTORY:

    Enter Approximate Dates If Applicable. (MM / YYYY)

  • DIAGNOSTIC TESTS:

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  • MEDICATION & SUPPLEMENT HISTORY:

  • PEDIATRIC PATIENT QUESTIONS:

  • Evaluation & Treatment History (tick all that apply)

  • CONSENT & PRIVACY FORMS: 

     

    We strongly encourage you to read these forms as they contain IMPORTANT information about your rights, attestations and financial terms.

     

    You MUST scroll to the bottom of each form to be able to check the box.

     

    * = required field

  • PARENTAL / GUARDIAN PRESENCE IN MINOR PATIENTS TREATMENT SESSION (patient ages 15-17)*
  • Text & Email Appointment Reminders Will Be Sent Unless A Single Preference Below Is Selected (not required)
  • Reload

  • Our expert doctorate therapists look forward to seeing you soon and helping get you get back to full health.

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