Client Intake Form

Current Condition/Chief Complaint

Please provide detailed information regarding the reason you are seeking treatment

Medical History

Waiver, Consent, & Financial Agreement

Nature & Scope of Services

I understand that I am receiving one‑on‑one, cash‑based physical therapy and wellness services from a licensed physical therapist at Godspeed Wellness & Recovery.

Services may include:

• Comprehensive physical therapy evaluation

• Functional movement and biomechanical assessment

• Therapeutic exercise and corrective movement training

• Manual therapy, including soft tissue and joint mobilization

• Neuromuscular re‑education

• Posture, gait, and ergonomic training

• Education on injury prevention and self‑management

• Wellness‑oriented interventions to improve mobility, strength, and performance

I understand that all services will be explained to me and that I may ask questions at any time.

Direct Access Acknowledgement

I understand that Tennessee law allows patients to receive physical therapy without a physician referral, provided the therapist meets state requirements.

I acknowledge that:

• I am choosing to receive services under Tennessee’s direct access laws.

• These services may be provided without prior medical diagnosis.

• If my condition does not improve as expected, or if symptoms fall outside the scope of physical therapy, I may be referred to a physician or other healthcare provider.

• I may seek medical evaluation at any time.

Cash-Based Care Disclosure

I understand and agree that Godspeed Wellness & Recovery operates on a cash‑based model.

I acknowledge that:

• Payment is due in full at the time of service.

• Godspeed Wellness & Recovery does not bill insurance on my behalf.

• I may request a superbill for potential out‑of‑network reimbursement, but reimbursement is not guaranteed.

• I am responsible for understanding my own insurance benefits.

• Medicare beneficiaries may only receive non‑covered wellness services unless a physician plan of care is established.

I understand that all fees, payment policies, and cancellation policies have been clearly explained.

Risk, Benefits & Expected Outcomes

I understand that physical therapy at Godspeed Wellness & Recovery is generally safe but may involve risks.

Potential Risks Include:

• Temporary soreness or discomfort

• Muscle fatigue

• Bruising or mild swelling

• Joint or soft tissue irritation

• Exacerbation of existing symptoms

• Lightheadedness or dizziness

Potential Benefits Include:

• Reduced pain and stiffness

• Improved mobility, strength, and function

• Enhanced posture and movement patterns

• Increased body awareness

• Improved performance in daily and recreational activities

I understand that outcomes vary, and no specific result is guaranteed.

Client Responsibilities

I agree to:

• Provide accurate and complete health information

• Communicate any changes in symptoms or medical status

• Inform the therapist immediately if I experience discomfort, dizziness, or unusual sensations

• Follow home exercise recommendations to the best of my ability

• Ask questions when I need clarification

I understand that my participation and communication directly influence my progress.

Consent to Treatment

I voluntarily consent to physical therapy evaluation and treatment at Godspeed Wellness & Recovery. I authorize the Physical Therapist to examine and treat the condition as they deem appropriate through the use of physical therapy measures. I authorize for these procedures to be performed.

I understand that:

• A physical therapy diagnosis is not a medical diagnosis by a physician

• A physical therapist cannot diagnosis an illness or disease

• I will not be subjected to any procedure without my voluntary, competent, and understanding consent or the consent of my legally authorized representative

• I may decline any intervention offered.

• I may withdraw consent at any time.

• I have the right to informed participation in decisions involving my health care

• The therapist will explain procedures and answer questions as needed.

• The therapist may modify or discontinue treatment if necessary for my safety.

• I may not hold the Physical Therapist responsible for any preexisting medically diagnosed conditions nor for any medical diagnosis

Release of Liability

To the fullest extent permitted by law, I release and hold harmless Godspeed Wellness & Recovery, its physical therapist, and any affiliates from liability for:

• Injuries

• Damages

• Losses

except in cases of gross negligence or willful misconduct.

I understand that physical therapy is not without risk, and I accept responsibility for my participation.

Privacy & Communication Consent

I consent to communication from Godspeed Wellness & Recovery via:

• Phone

• Email

• Text message

I understand that electronic communication may not be encrypted and may carry privacy risks. I acknowledge that my information will not be shared without my consent except as required by law.

Acknowledgement of Policies

By signing, I acknowledge that I have reviewed and understand:

• Payment and refund policies

• Cancellation and no‑show policies

• Cash‑based service structure

• Direct access guidelines

• My responsibility to provide accurate health information