Templates & intake packets

Your name

Email

Your message

Your name

Email

Will you attend?

How would you rate your experience?

What did you like most?

How likely are you to recommend us?

Client name

Date of service

Invoice number

First name

Last name

Email

Your name

Email

Which session?

Name

Work email

Phone (optional)

Question 1

Question 2

Question 3

About you

Full name

Date of birth

Consent to treatment

I understand that physical therapy may include evaluation, manual therapy, therapeutic exercise, modalities such as heat, ice, or electrical stimulation, gait and balance training, and education. My therapist has explained the expected benefits, the possible risks (such as temporary soreness), and the alternatives, and I have had the chance to ask questions. I understand that no guarantee has been made about the results of treatment. I may refuse or stop any part of my treatment at any time. I will tell my therapist right away about any change in my health, pain, or medications.

I voluntarily consent to evaluation and treatment by [Practice Name]

Neck Disability Index (Vernon H, Mior S, 1991). This questionnaire shows how neck pain affects your everyday life. In each section, choose the ONE statement that best describes you today. If two seem to apply, pick the closest one.

Patient name

Visit type

Our cancellation policy

We hold each appointment time just for you. When a visit is missed without notice, another patient loses the chance to be seen. <ul><li><strong>24-hour notice:</strong> Please cancel or reschedule at least 24 hours before your appointment.</li><li><strong>Late cancellation:</strong> Cancellations with less than 24 hours' notice may be charged a $[XX] fee.</li><li><strong>No-show:</strong> Missed appointments without notice may be charged the full visit fee.</li><li><strong>Late arrival:</strong> If you arrive more than 15 minutes late, we may need to shorten or reschedule your visit.</li></ul> We understand emergencies happen. Fees may be waived at the practice's discretion.

How to cancel

Fill this out each day you do your home exercises. It takes under a minute, and it helps your therapist adjust your program between visits.

Your name

Date

About you

Full name

Date of birth

Patient information

Full name

Date of birth

About you

Full name

Date of birth

Participant

Full name

Date of birth

If you are in crisis or thinking about harming yourself, call or text 988 (Suicide & Crisis Lifeline) or call 911. This form is not monitored in real time.

About you

Full name

What therapy involves

Therapy is a collaborative process. Sessions are usually [50] minutes. Benefits can include relief from distress and better relationships, but therapy can also bring up uncomfortable feelings. Progress depends on your participation, and no specific outcome is guaranteed. You may end therapy at any time.

I understand what therapy involves

Client

Client full name

Client date of birth

This takes about one minute. Honest answers help your therapist make sessions more useful for you.

Session date

I felt heard, understood, and respected (0 = not at all, 10 = completely)

Welcome! Please fill this out at least 48 hours before check-in so we can get everything ready for you.

Lead guest

Full name

House rules

Thank you for staying with us. Please read and agree to each rule below.

Quiet hours are 10 pm to 8 am. No parties or events.

Report details

Your name

Your role

Cleaner name

Property

Turnover date

Tell us about your project and we'll send a quote within [1 business day].

Your details

Name

Welcome aboard! These answers help us start strong. It takes about 5 minutes.

Contact

Your name

Client

Full name

Phone number