Name *

First Name

Last Name

Phone *

(###)

###

####

What type of treatment are you interested in? *

In-person therapy (Denver)

Virtual coaching

Not sure- I need guidance

What pelvic health concerns are you experiencing? *

Please check all that apply

Leakage

Urgency to urinate

Urinary frequency

Low back, SI joint, or hip pain

Pain with intimacy

Lack of sexual arousal

Pelvic pressure/heaviness (prolapse)

Menopausal or perimenopausal symptoms (dryness, irritation, changes in bladder/bowel habits)

Constipation

Pregnancy Pain

Core or abdominal weakness / diastasis recti

Rib flaring

Tailbone pain or sitting discomfort

Painful urination/bowel movements

Frequent UTIs

Other not listed

How long have you been struggling with this issue? *

<6 months

1 year

1-2 years

2 + years

How often do these symptoms bother you? *

100% of the time

75% of the time

50% of the time

25% of the time

Rarely

Are you ready and willing to invest time and financial resources into your pelvic health? *

Please select the option that best reflects your current situation:

Yes, I'm so ready!

No, I’m not currently in a place to invest in this kind of support, even though I know I want to heal.