Discovery Consultation Please complete this form to send your question to our knowledgeable therapists. But, please do not send any confidential medical information, as email is not a secure method of communication. Name* First Last Email* Phone*What problems are you experiencing?*Urinary frequency or leakageBowel ProblemsSexual PainPelvic PainAbdominal Muscle SeparationBack PainHip PainProlapseOtherDescription:*How does this effect your daily life?*What is your chief goal?*How would you prefer to communicate with one of our Physical Therapists:*Phone consultationIn person free discovery visitWhat time of day are you available?*Morning (7am - 11 am)Noon (12pm - 3pm)Evening (4pm -7:00pm)EmailThis field is for validation purposes and should be left unchanged.