New Client Information

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Please fill out this form to request a New Client Assessment with Seth Hodosh, owner and CEO of Bridging The Gap. Welcome to the family! We are so excited to serve you on your path to success. Balance, mobility, and strength are key to helping everyone grow through their personal journey. Feel free to contact us at anytime!

HIPPA Notice: Please keep in mind that communications via email and Google Form are not secure. The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws, including HIPPA regulations. It is intended only for the use of the person(s) named above (Bridging the Gap). If you are not the intended client, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by email and destroy all copies of the original message.

Client First Name *

Client Last Name *

Address of Where We are Meeting for Sessions (Street, City, and Zip) *

Client Phone Number *

Client E-Mail *

Client Date of Birth *

YYYY

By checking this box, you acknowledge and agree to the stated terms and conditions. This is for the INTAKE session only, and can be found HERE. This agreement has been digitally approved and is legally valid. *

Yes

By selecting YES, you acknowledge and agree to the stated terms and conditions. This is for the CLIENT SERVICE AGREEMENT, and can be found HERE. This agreement has been digitally approved and is legally valid. The price will be discussed at the Initial Client Evaluation and follow with a DocuSign to the billing email. *

Yes

Which E-Mail should we use for billing? *

If you have an E-Mail we should send a DUPLICATE invoice to, please list it here.

I understand that the Initial Client Evaluation costs $85 (billed to e-mail above). *

Yes

Emergency Contact Name *

Emergency Contact Phone Number *

Do you (CLIENT) accept this form as a digital signature that the information is correct? *

Yes

POA/Guardian Has Signatory Power

Do you (POA/Guardian) accept this form as a digital signature that the information is correct?

Yes

Not Applicable

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