Inclusive Care "Pay What You Can" Initial Consultation Application

At Inclusive Care, we are committed to providing accessible and trauma-informed healthcare services to everyone. Our "Pay What You Can" policy is designed to ensure that individuals from all walks of life can access the care they need. We welcome all individuals, regardless of their financial situation, and encourage those who may face financial challenges to utilize this policy. Additionally, we are committed to addressing health disparities and promoting inclusivity in healthcare. As part of this commitment, we prioritize applications from BIPOC (Black, Indigenous, People of Color) and TNB (Transgender, Non-Binary) individuals.

Thank you for your interest in our pelvic floor physical therapy services. Please take a few moments to complete this screening form to your level of comfort so that we can better understand your needs and provide you with the best possible care.

Once you've completed the form, please click the "Submit" button. We will review your information and reach out to you as soon as possible to discuss scheduling an appointment.

Thank you for entrusting us with your healthcare needs. We are committed to supporting you on your journey to better pelvic health and overall well-being.

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Name
Age
Email
Phone Number
Address
Please check all possible communication options
Please describe aspects of your identity that you feel are relevant to your healthcare experience (examples: race, ethnicity, sexual orientation, gender identity, disability status, etc.)

Briefly describe why you are seeking an appointment at Inclusive Care. Please note how long you've been experiencing these symptoms.

Do you require any accommodations to access our services (e.g., wheelchair accessibility, interpreter services, etc.)?
Please choose your current insurance
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Pay What You Can means that you're able to opt in to any amount. We provide these four tiers as a reference, but please feel free to add "Other". 

For context, initial evaluations are typically $275 and follow ups are typically $195. 
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What else do you want us to know?
Are there any questions we can answer for you?

Consent and Privacy:

By submitting this form, you acknowledge that all information provided will be kept confidential and used solely for the purpose of providing healthcare services.
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