Sacral Function Therapy, PLLC

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

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State

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Reason for care

What is the reason for seeking care?

This is a non-exhaustive list. If you don't see the option you are looking for, please select 'other.' You will have an opportunity to explain further.

Chronic Pelvic Pain Bladder Incontinence Bowel Incontinence Pelvic Organ Prolapse (POP) Gender Affirming Care General Sexual Wellness or Intimacy Dysfunction Other

I am interested in addressing...

You can specify your goals and treatment preferences here. Ex: "Continence goals so I can confidently go out to dinner with friends."

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If you responded with "Other" to the previous question, please describe here:

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Administrative

Inquiry reason

Billing & Payment

Will you require a superbill to submit to insurance for out-of-network claims?

Yes No Unsure

Client Preferences

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, concerns about therapy, beliefs/customs/values that the therapist should consider, questions regarding payment, etc.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.