Physical Therapy Inquiry Form
Physical Therapy Inquiry Form (Children & Adults)Thank you for your interest in Physical Therapy services at Rise Therapy & Wellness. This form helps us understand your needs and determine next steps. Completing this form does not guarantee services and does not establish a provider–client relationship.
Contact Information
Name of person completing this form
*
First Name
Last Name
Relationship to client (if applicable):
*
Self
Parent
Caregiver
Other
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Preferred Contact Method
*
Email
Phone
Either
Client's Name
*
First Name
Last Name
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Age
*
Reasons for Physical Therapy (Select all that apply)
*
Gross Motor Delays
Balance or Coordination Challenges
Muscle weakness or low endurance
Pain, injury, or recovery from injury
Sports-related concerns
Gait or posture concerns
Developmental delays
Neurological conditions
Post-surgical support
Functional mobility concerns
Pain
Other
Areas of Impact
*
Home
School
Sports and recreation
Community activities
Other
Please describe the reason for your inquiry or the symptoms you are experiencing.
*
Are you currently receiving physical therapy or have you in the past?
*
Yes
No
Availability
Preferred Days/Times for Appointments
*
Insurance and Payment
Do you/client have insurance?
*
Yes
No
Unknown
How did you hear about us?
*
Please Select
Doctor Referral
Friend/Family
Online Search
Social Media
Other
Consent & Acknowledgment
I understand that submitting this inquiry form does not guarantee services and that Rise Therapy & Wellness will contact me to discuss availability, next steps, and required documentation.
Signature
*
Date of Signature
*
-
Month
-
Day
Year
Date
Thank you for your interest.
Rise Therapy & Wellness provides neuro‑affirming, relationship‑centered Physical Therapy services for children and adults. Because how you feel in a space matters.
Submit Inquiry
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