Resilient Consultation Intake Form
Thank you for your interest in a Resilient Consultation! Once I return from maternity leave, I look forward to chatting with you and helping you troubleshoot symptoms you may be experiencing. Before I reach out to you to schedule, I would appreciate if you let me know a few things about your health history and why you are inquiring about a Resilient Consultation. Filling out this form puts you on my waitlist to reach out to schedule. Thank you for your time and interest and thank you big time for understanding!

Your Name? *
Your email *
Where are you in your motherhood journey?
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If you're experienced birth, how many births have you experienced? *
What type of fitness are you currently doing? (Mark all that apply)
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Required
Are you or have you ever experienced pelvic floor dysfunctions such as leaking (pee or feces), pain, pressure, or heaviness
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If yes, what and when do you experience dysfunction (please be as specific as possible)
Are there any specific exercises or activities of daily living where you are experiencing pelvic floor and or core dysfunction? (if none, write "no")
Have you ever been checked for diastasis recti?
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Do you know if you have diastasis recti? *
If yes, do you know how wide and how deep and where on your abdomen it is presenting? (please be a specific as possible
Have you ever been seen by a Pelvic Floor Physical Therapist? *
If yes, what were you seen for and what did she diagnose you with?
Please describe what you do for your occupation and whether you spend most of it sitting, standing, or evenly split? *
What are you wanting to get out of our time together? (please be as specific as possible)
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Is there anything else I should know about you or your health history or motherhood journey that would influence our time together? *
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