Intake Questionnaire & Liability Release

Please fill out the following form.

Full name

Email

Phone

Date of birth

Month

Day

Year

Why are you here? What do you need help with?

Are you in pain? If so, where, and please scale it 1-10.

How long have you had this issue? What exercises/physical therapy are you currently doing? Does it help?

Describe the environment/activities you do most of the day, ie sitting, standing, waiting tables, driving in a vehicle, etc.

Where did you hear about Movement Therapy Company? How did you find me?

I, the undersigned, release Jamie Elmer, First Ray Yoga LLC, from all liability/responsibility related to, but not limited to, the information & physical actions provided in this & all future events, meetings, advice, both written & spoken.

Helping you feel better!

Movement Therapy Company

Intake Questionnaire & Liability Release

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