New Client Intake Form

Website Content Collection Form

MYOFUNCTIONAL THERAPY
If you need to stop and continue later, please just use the "Save" button at the bottom of the form, then close the window. You'll receive sent an email with a link to continue from where you left off.
Personal Information
Client Name*

First NameLast Name
Credentials (if applicable)
RDH, SLP, etc.
Email*
example@example.com
Phone Number*
Please provide a valid phone number.

Business Information
Business Name*
As you wish it to appear on your logo & website. ("LLC" not required at the end of name even if the business is a registered LLC.)
Business Email
(If different from personal email).
Secondary Email (Optional)
(Ex. info@myomoves.com)
Office Phone
This should be your main office phone number. This should match the number you plan to put on your Google business page.
Fax or Alternate Number (Optional)
Fax or other alternate phone.
Business Address (should match what you have listed on Google Business page)

Street Address

Street Address Line 2

CityState

Zip Code
Only check this box if you DO NOT want your business address listed on your website. Such as if you only do virtual visits or work out of another provider's location.

Do not list my address

Domain

www.domain.com | Domains are NOT hosting, Ex. A residential house is the server, the address on the mailbox is the domain.
Do you currently own a domain?

Yes, and I can provide access to itNo, I need to purchase oneI need some help with thisOther
If you are using GoDaddy for your domain, please read these instructions for giving access to your account. We prefer for you to add us as a user, rather than sharing your login credentials for security & liability purposes.

Please use the email justin@levitate-creative.com to add user.

Graphics & File Uploads

Please upload the following files. If sending multiple files for each, it's better to compress them all in a zip file first.
Logo & Graphics
If you have multiple versions of your logo, such as a vertical and horizontal orientation, please upload all of them.

Vector format is preferred (.svg, .ai., .eps, .pdf), but .png also works well.
Logos + Graphic files

Cancelof
Headshot(s)

+other photos
Headshot(s) & Other Photos you'd like to use on the site.
Take Photo (optional)
Documents

Cancelof

Services
Please list your services with name, short description of each, duration, price, and anything else you'd like to have listed.
Ex. Initial Consultation - Spend 30 Minutes with us getting to know you and see if Myo is right for you. 30 min virtual call, $100.
Type of Appointments:*

In-PersonVirtual OnlyHybridOther

Team/About Us
Provide team member names, with credentials, and a short bio. You can type them out here or upload a Word document below.
Certifications & Memberships
Document upload

Word docs and/or Certification badges & images.
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SimplePractice Appointment Request Widget

For Patient Portal / Booking Appointments
Click here to see instructions on how to find your code. Once you've found it, simply copy and paste the entire code in the box below.
Copy/paste code below

Website Content Collection Form