Bridging the Gap Client Intake Form
Welcome to the family! We are so excited to serve you on your path to success. Balance, mobility, and strength are key to helping everyone grow through their personal journey. Feel free to contact us at anytime!

HIPPA Notice: Please keep in mind that communications via email and Google Form are not secure. The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws, including HIPPA regulations. It is intended only for the use of the person(s) named above (Bridging the Gap). If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by email and destroy all copies of the original message.
登入 Google 即可儲存進度。瞭解詳情
Client First Name *
Client Last Name *
Client Phone Number *
Client E-Mail *
Client Date of Birth *
MM
/
DD
/
YYYY
Address of Where We are Meeting for Sessions *
Have you read the Liability and Waiver? (https://drive.google.com/drive/u/0/my-drive) *
Do you understand the Cancelation Policy? *
Do you agree to the COVID-19 Policy? *
Can we use your image for social media, yelp reviews, or website purposes? *
Which E-Mail should we use for billing? *
Emergency Contact Name *
Emergency Contact Phone Number *
Emergency Contact E-Mail *
Primary Doctor Name and Phone Number
Current diagnosis or disability?
Please list all medications, dosages, and frequency.
Do you (CLIENT) accept this form as a digital signature that the information is correct? *
Do you (POA/Guardian) accept this form as a digital signature that the information is correct?
清除選取的項目
提交
清除表單
請勿利用 Google 表單送出密碼。
Google 並未認可或建立這項內容。 檢舉濫用情形 - 服務條款 - 隱私權政策
Google 表單