New client application

Intake screening form

Before you submit the form

To ensure we are the right fit for your clinical goals, all new clients undergo an initial screening. I specialize in evidence-based, focused soft-tissue management and goal-oriented, progressive treatment plans. Please continue with this form only if you are currently working with a multidisciplinary healthcare team, are willing to actively participate in your recovery, and can commit to a consistent (at least monthly) treatment plan.

If you are looking for general relaxation, Swedish massage, or cannot commit to a monthly regimen at this time, please let me know and I would be happy to refer you to some wonderful local LMTs who specialize in those areas.

* Required

General & administrative

First name *

Last name *

Email *

Phone number *

Please enter your full 10-digit phone number.

Occupation *

Health & care integration

1. Are you currently working with a healthcare professional or specialist (for example, a physical therapist, primary care physician, or orthopedist) for the physical issues you want to address? *

Yes No

2. If accepted into the practice, are you comfortable with functional progress updates being provided to your current care team if necessary? *

Yes No N/A

Movement goals & physical limitations

3. What specific physical goals or functional improvements do you hope to achieve through clinical manual therapy? *

For example: improving shoulder overhead reach, sitting comfortably for work, or reducing pain during a specific activity.

4. What daily movements, work tasks, or lifestyle activities are currently most restricted or uncomfortable? *

5. How long has this specific physical limitation or movement pattern affected you? *

6. What other types of care or exercises have you tried for this issue, and did they help your movement? *

Practice alignment & screening acknowledgement

I acknowledge that this practice operates on an evidence-based, clinical manual therapy model focused strictly on functional outcomes and objective pain management. I understand that achieving these results is a partnership that requires my active participation and a commitment to personalized at-home self-care strategies between sessions. I understand that this is an assessment-driven clinical intervention and is not a general relaxation, Swedish, or spa-style massage. *

I understand that because clinical work requires consistent momentum to be effective, this practice exclusively accepts clients who can commit to a regular, at least monthly, treatment schedule. I agree to prioritize this schedule to achieve my long-term movement goals. *

Your answers go directly to Whitney and are used only to review your application.