The following is a survey to see whether you would be a good candidate to begin pelvic floor physical therapy. This is a no pressure, complimentary service and does not commit you to anything.

The following questions can feel extremely sensitive, so please know that your answers will be kept under the strictest confidentiality by our physicians. We appreciate your honesty. By completing this form I understand and agree to release my protected health information to Rise Women's Core Wellness.

If we feel that you would benefit from pelvic floor physical therapy, we will contact you via your preferred form of contact.