Discovery Contact Form

Kindly complete the form below with your information. A member of our clinical team will reach out within 24 hours to discuss your needs and determine the most appropriate next steps in your care. We appreciate your interest in Ascend PTP.

First Name *

Last Name *

Date of birth *

Phone *

Email *

Where Does It Hurt? *

If Other Please Describe Here (optional)

What concerns you the most that makes you want to consider physical therapy?

Select the level of impact your pain/ problem has on your lifestyle *

It is annoying but doesn't limit my function

I am able to perform all daily tasks and activity but I am scared to push beyond my comfort zone

I am able to perform daily tasks and baseline activity but unable to perform at desired level of intensity due to pain

I am able to perform daily tasks but unable to participate in recreational activity/ exercise

The pain limits me from performing daily tasks and all recreational activity/ exercise

The #1 thing you would like to achieve from physical therapy: *

On a scale of 1-10 how committed are you to helping yourself achieve your goals?

Who can we thank for referring you to us?