Pre-Screening - Santiago Movement & Performance

Pre-Screening Form

- Step 1 of 3

Name *

First

Last

Email *

Phone *

Date of Birth *

Occupation

Name *

First

Last

Phone *

Relationship *

Describe the problem you are looking for help with? *

How long have you been experiencing this problem? *

Do you have any big goals that you'd like me to help you achieve? *

Finish this sentence: “If I didn’t have this problem, I would be….” *

Please outline any past medical history (allergies or underlying conditions?) *

Do you have or had any of the following? *

Have you ever received any form of therapy for this particular problem?

Which type of therapy?

How did it helped?

How Long did it help?

Did the symptoms return?

Consent *

By clicking this box I consent to the general T&C and specifically consent to undertake a consultation and treatment guided by Edwin Santiago

Todays Date *

Signature