This is a self-reported survey of which responses will be used for research purposes only. Upon completion and submission of this survey, you as an individual authorize the release of information for such purposes. 

The Unique Research Identification Number below uses two HIPAA Individually Identifiable Health Information elements (Initials and Date of Birth) which will be used to cross reference your survey responses for different experiences or for the same experience over time. 

The Unique Research Identification Number will not be disclosed at any point to third parties or otherwise as part of the research and data analysis process and will only be used internally by The Kinaesthetic Connection.

I acknowledge that all information shared via this form is being shared freely and voluntarily. I accept the above terms and conditions and upon submission of this form, recognize there can be no legal implications, claims or liability against The Kinaesthetic Connection related to any information shared via this form.